Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much this bothers them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

Postal Code:
Phone number:

1. Please select your age

2. Are you (Tick one): Female Male

3. How often do you leak urine ? (Tick one box)
0- never
1- about once or less a week
2- two or three time a week
3- about once a day
4- several times a day
5- all the time

4. We would like to know how much urine you think leaks How much urine do you usually leak (whether you wear protection or not)? (Tick one box)
0- none
1- a small amount
2- a moderate amount
3- a large amount

5. Overall, how much does leaking urine interfere with your everyday life? Please choose a number between 0 (not at all) and 10 (a great deal)

6. Do you experience, and if so, how much are you bothered by....
- Frequent urination
- Leakage related to feeling of urgency
- Leakage related to physical activity, coughing or sneezing
- Small amounts of leakage (drops)
- Difficulty emptying bladder
- Pain or discomfort in lower abdominal or genital area