PATIENT INFORMATION

Urinary Incontinence Impact Questionnaire
Practice Location

SECTION 1: The below questions are designed to assess how severely urinary incontinence (the unintentional loss of urine) affects you. Please answer as honestly and clearly as possible when answering these questions.
ONLY ONE OPTION PER QUESTION MAY BE SELECTED

SECTION 2: The below questions ask about how urinary incontinence affects your activities, relationships and feelings. Please answer as honestly and clearly as possible when answering these questions which refer to areas of your life that have been influenced by urine leakage.
Please only check answer per question