ICIQ-UI Incontinence Questionnaire Question Title * 1. Please type your name. Surname, First Name 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. Please choose the most appropriate answer for the following questions. Question Title * 2. How often do you leak urine? 0 never 1 about once a week or less often 2 two or three times a week 3 about once a day 4 several times a day 5 all the time Question Title * 3. We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? 0 none 1 a small amount 2 a moderate amount 3 a large amount Question Title * 4. Overall, how much does leaking urine interfere with your everyday life? 0 not at all 1 2 3 4 5 6 7 8 9 10 a great deal 0 not at all 1 2 3 4 5 6 7 8 9 10 a great deal Question Title * 5. When does urine leak? (Please select 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 Question Title * 6. Interpretation of scores (for office use only)Total score: (add up scores) = _______ SCORE RANGE = slight 1-5, moderate 6-12, severe 13-18, very severe 19-21 ICIQ-UI SF Reference: Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourology and Urodynamics: Official Journal of the International Continence Society. 2004;23(4):322-30. Done
