Symptom Questionnaire

There are 3 basic types of bladder control problems: overactive bladder, stress incontinence and mixed incontinence. A urinary tract infection is another kind of condition that may appear to be a bladder control problem but is not. Prostate problems and bladder stones also fall into this category.

If you answer "yes" to any of these questions, print this page and take it with you when you go to see your doctor. Alternatively, download this bladder questionnaire.

Symptoms of an Overactive Bladder

Q1 Do you frequently have a strong, sudden urge to urinate?
Yes No

Q2 Do you sometimes not make it to the bathroom on time?
Yes No

Q3 Do you frequently go to the bathroom more than 8 times per 24 hours?
Yes No

Q4 Do you get up 2 or more times during the night to go to the bathroom?
Yes No

Symptoms of Stress Incontinence

Q5 Do you experience a loss of urine when you are doing physical activities, such as lifting
heavy objects or exercising?
Yes No

Q6 Do you sometimes have a slight loss of urine when you sneeze, cough, or laugh?
Yes No

Mixed Incontinence

Q7 Have you answered yes to the symptoms of both an overactive bladder and stress incontinence (see above)?
Yes No

Symptoms of a Urinary Trace Infection

Q8 Do you experience a burning sensation when you urinate
Yes No

Q9 Do you frequently have a strong, sudden urge to urinate?
Yes No

Q10 Do you only pass a small amount of urine when you urinate?
Yes No

Q11 Do you have cloudy or bloody urine?
Yes No

Q12 Do you experience lower back or abdominal pain?
Yes No

Q13 Did your symptoms come on suddenly?
Yes No

Symptoms of a prostate problem/bladder stones

Q14 Do you experience pain when urinating?
Yes No

Q15 Do you get a weak and interrupted flow during urination?
Yes No

Q16 Do you need to urinate frequently during the day and night?
Yes No

Q17 Do you have a constant feeling that your bladder is never empty?
Yes No

Q18 Do you have blood in your urine?
Yes No

Q19 Are you sometimes unable to urinate?
Yes No

Q20 Do you have difficulty in beginning to urinate even when the bladder is full?
Yes No

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