Voiding symptoms questionnaire

Address:
Telephone Number:
Date of Birth:
Social Security Number:
Marital Status:
Mother’s First Name:
Father’s First Name:

Medical History Questionnaire
1. Do you have any of the following heart problems?
 heart murmur  chest pain  heart attack  rheumatic fever  irregular heart beat  shortness of breath  high blood pressure  mitral valve prolapse  coronary artery disease  Other__________________________________________ COMMENTS:
2. Do you have any of the following lung problems?
 emphysema  cough  shortness of breath
3. Have you ever had any of the following blood problems?

4. Have you ever been treated for or do you have any of the following?
 thyroid disease  hepatitis  glaucoma  frequent fevers  frequent vomiting  frequent diarrhea  vision problems  problems with hearing
5. Do you have any of the following psychiatric problems?
 extreme nervousness  extreme anxiety 6. Have you ever had any of the following nervous, muscular or neurologic problems?
 YES  NO
 insulin dependent diabetes
 noninsulin dependent diabetes  dizziness  spinal bifida  spinal stenosis  other_____________
Do you have neurologic symptoms?
What symptoms do you have and for how long?
If you have a spinal cord injury, what ZONE level is the injury?
Cervical

7. Please check the boxes that apply to your kidney and bladder problems.

8. Have you had any of the following urologic or gynecologic surgery?  YES  NO
What surgery did you have and when was the procedure?

 Other___________________________ ______
9. Have you had any other surgery?

10. Have you ever been hospitalized for anything else or do you have any other medical
problem to report?  YES

11. Do you take medications regularly?

12. Has anyone in your family been treated for cancer?  YES  NO
COMMENTS:

13. Are you a smoker?

14. Do you drink alcohol?  YES  NO

15. Do you drink any of the following?

16. Are you allergic to any medications?  YES  NO
Please give the names of the medications.


If female:
17. How many children have you had?
 none  one  two  three  four  five  six  seven
18. What is your menstrual status?
 post-menopausal
 irregular menstruation  regular menstruation  partial hysterectomy  total hysterectomy Name: I have read and answered all of the questions in their entirety and the information is accurate and true to the best of my knowledge. Voiding Symptoms Questionnaire

1. What are your most troublesome urinary complaints?
 Frequency ( Urinating Often)  Urgency
 Stress Incontinence (loss or leakage of urine when coughing, sneezing, etc.)  Urge Incontinence (can’t hold urine with an urge)  Pain
2. How long have you had your bladder or urinary problems?
Select Time Number:1 2 3 4 5 6 7 8 9 10 11 12
Time Unit:

3. How often do you urinate during the daytime?
Average Time Interval: 1 2 3 4 5 6 7 8 9 10 15 20 25 30 90 Maximum Time Interval: 1 2 3 4 5 6 7 8 9 10 15 20 25 3090 Minimum Time Interval: 1 2 3 4 5 6 7 8 9 10 15 20 25 30 90 4. Why do you urinate as often as you do?
 normal urge

5. How many times do you get up to urinate at night?
1

6. Why do you get up to urinate at night?
 awakened by urge to urinate  you're already up  afraid you might wet the bed  habit  N/A
7. How often is there a sense of urgency?
 never
 a few times a month  once a month  a few times a week  once a week  once a day  a few times a day
8. When you get the urge to urinate, is the urge controllable?  YES

How long can you hold it or control it before you lose control?
Time Interval: 1 2 3 4 5 6 7 8 9 10 15 20 25 3090 Time Unit: 9. How often do you lose control of urination because you feel a strong urge and cannot
control it?
 never
 a few times a month  once a month  a few times a week  once a week  once a day  a few times a day
10. Do you leak urine or lose control of urination?
11. Do you wear pads or other form of protection because of wetting?  YES

12. About how many pads do you use a day?
1

13. How wet are they when you change them?
 dry

14. Do you know what happens or do you just find yourself wet?
 know what happens

15. How often do you lose control when you cough or sneeze?
 never
 a few times a month  once a month  a few times a week  once a week  once a day  a few times a day
16. How often do you lose control when you engage in physical activity such as running or
jogging?
 never
 a few times a month  once a month  a few times a week  once a week  once a day  a few times a day
17. How often do you lose control when you raise yourself from a sitting to a standing
position?
 never
 a few times a month  once a month  a few times a week  once a week  once a day  a few times a day
18. What method do you use to start urinating?
 none  straining  crede  tapping  catheterize
19. Does it take a while before you start urinating?

20. How long does it take to start urinating?
Time Interval: 1 2 3 4 5 6 7 8 9 10 15 20 25 3090
Time Unit:

21. How would you describe the usual force of the stream?
 strong  weak
 interrupted  intermittent  variable  not as strong as it used to be
22. How often do you feel that you have not emptied your bladder after urinating?
 never
 a few times a month  once a month  a few times a week  once a week  once a day  a few times a day
23. Have you ever been unable to urinate and required a catheter in order to empty your
bladder?

24. Do you use condom catheters or indwelling catheters?

25. Do you use intermittent catheterization to empty your bladder?
How often?
qD BID TID QID q 1-2 hours q 3-4 hours q 5-6 hours q 7-8 hours
 q 9-10 hours  q 11-12 hours

26. Have you ever had, or been told, you had blood in your urine?


27. Do you have pain during urination?  YES
What type of pain do you have?
What location do you feel pain?

28. If Female, do you think that you have a dropped bladder or a bulge in the vagina?

29. Have you taken any medications for your bladder condition in the past?  YES  NO
COMMENTS:
Please Check Off Urologic Medications That You Are Taking

30a. Any anticholinergics?

30b. Any antispasmotics?

30c. Any anticonvulsants?  YES  NO

30d. Any alpha-blockers?  YES  NO
 Cardura (Doxazosin)

30e. Any antiandrogens?

30f. Any alpha agonists?

30g. Any diuretics?

31h. Any antihistamines?

30i. Any other bladder medications?

AUA Symptom Score
have you had as sensation of not emptying your bladder completely after urinating? have you had the urge to urinate again less than two hours after you finished urinating? have you found you stopped and started again several times when you urinated? have you found it difficult to postpone urination? have you had to push or strain to begin urination? did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? AUA Symptom Score = sum of questions 1-7

Source: https://www.cornellurology.com/images/uploads/Office-Questionnaire-medical-urologic-history.pdf