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ICIQ-UI Short Form
This survey is designed to find out whether you leak urine and how much this bothers you. Please answer the following questions, thinking about how you have been over the last FOUR (4) weeks
* Indicates required question
Email
*
Your email
Name
*
Your answer
Over the past 4 weeks, how often do you leak urine?
*
Never
About once a week or less
Two or three times a week
About once a day
Several times a day
All the time
We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? (over the past 4 weeks)
*
None
A small amount
A moderate amount
A large amount
Overall, over the last 4 weeks, how much does leaking urine interfere with your everyday life?
*
not at all
0
1
2
3
4
5
6
7
8
9
10
a great deal
When does urine leak? (please tick all that apply to you)
*
never - urine does not leak
leaks before you can get to the toilet
leaks when you cough or sneeze
leaks when you are asleep
leaks when you are physically active/exercising
leaks when you have finished urinating and are dressed
leaks for no obvious reason
leaks all the time
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