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| (1) How often do you usually urinate during the day? | |
| (2) How many times do you usually urinate during the day? | |
| (3) How often do you usually urinate during the night? | |
| (4) How many times do you usually urinate at night? (from time you go to bed until time you wake up for the day) | |
| (5) What is the reason that you usually urinate? | |
| (6) Once you get the urge or desire to urinate, how long can you usually postpone it comfortably? | |
| (7) How often do you get a sudden urge or desire to urinate that makes you want to stop what you are doing and rush to the bathroom? | |
| (8) How often do you get a sudden urge or desire to urinate that makes you want to stop what you are doing and rush to the bathroom but you do not get there in time? (leak urine or wet pads) | |
| (9) How often do you experience urine leakage when you sneeze or cough? | |
| (10) How often do you experience urine leakage when you lift and bend? | |
| (11) How often do you experience urine leakage when you change positions? | |
| (12) How often do you experience urine leakage related to physical activity? | |
| (13) How often do you wet yourself, your pads or your clothes without any awareness of how or when it happened? | |
| (14) In your opinion how good is your bladder control? | |
| (15) How often do you have a sensation of not emptying your bladder completely? | |
| (16) How often do you stop and start during urination? | |
| (17) How often do you have a weak urinary stream? | |
| (18) How often do you push or strain to begin urination? | |
| (19) How bothered are you by your bladder symptoms? | |
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