CONFIDENTIAL

ICIQ Assessment Form

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.

Privacy key:

This is known only by yourself and your assigned clinician and is used to help us track progress

1. Date of Birth:

2. Gender:

3. How often do you leak urine?

never

about once a week or less often

two or three times a week

about once a day

several times a day

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)

none

a small amount

a moderate amount

a large amount

5. Overall, how much does leaking urine interfere with your everyday life?

Please select a number between 0 (not at all) and 10 (a great deal)

6. 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

Thank you very much for answering these questions