Table 2

International Consultation on Incontinence Questionnaire Urinary Incontinence—Short Form (ICIQ-UI SF)

1. Please write in your date of birth:□□ □□ □□
date month year
2. Are youFemale □ Male □
3. How often do you leak urine?
(Tick one box)
never0
about once a week or less often1
two or three times a week2
about once a day3
several times a day4
all the time5
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)
None0
a small amount2
a moderate amount4
a large amount6
5. Overall, how much does leaking urine interfere with your everyday life?
Please ring a number between 0 (not at all) and 10 (a great deal)
0 1 2 3 4 5 6 7 8 9 10
not at all a great deal
ICIQ score: sum scores 3+4+5□□
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 have finished urinating and are dressed
leaks for no obvious reason
leaks all the time