Urine Function Assessment

Circle "Yes" or "No" for each question.
 

Does the sudden urge to urinate send you rushing to the nearest restroom?

Yes    No

Do you visit the bathroom more than eight times in a 24-hour period?

Yes    No

Does delaying going to the bathroom ever result in wetting accidents?

Yes    No

Do you ever leak urine when you cough, sneeze, or bend over?

Yes    No

Are you going to the bathroom several times a night?

Yes    No

Does access to a bathroom decide where or if you travel or go shopping?

Yes    No

Do you have a problem with constipation?

Yes    No

Do you have any burning or pain when you urinate?

Yes    No

Have you had urinary problems since starting a new medication?

Yes    No

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.