Mesa Incontinence Questionnaire

NAME:  ___________________________________DATE: _____________
PHONE:                ______________  E-Mail:________________________________
Please check the appropriate box:

Urge Incontinence Questions

Some people receive very little warning and suddenly find that they are losing, or about to
lose, urine beyond their control. How often does this happen to you?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

If you can't find a toilet or find a toilet that is occupied and you have an urge to urinate, how often do you end up losing urine and wetting yourself?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Do you lose urine when you suddenly have the feeling that your bladder is full?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does washing your hands cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does cold weather cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does drinking cold beverages cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

TOTAL URGE SCORE ___________
URGE SCORE RATIO ___________

Stress Incontinence Questions

Does coughing gently cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does coughing hard cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does sneezing cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does lifting things cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does bending over cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does laughing cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does walking briskly cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does straining, if you are constipated, cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

Does getting up from a sitting to a standing position cause you to lose urine?
______Often (3) ____Sometimes (2) _____Rarely (1) Never (0)_____

TOTAL URGE SCORE ___________
URGE SCORE RATIO ____________

Add the total score for each category. For urge incontinence, the maximum total score is 18 based on 6 questions, with a maximum score of 3 for each question. For stress incontinence, the maximum score is 27, based on a question with a maximum score of 3 for each question. To determine predominance of either stress or urge incontinence, the percent score is obtained (by dividing the score by the maximum total possible score, e.g., 9 urge score divided by 18 x 100 = 50% urge vs. 9 stress score divided by 27 x 100 = 33%. Urge is considered predominant when the % score of urge is greater than stress.

Print this Questionnaire and fax to our office for a free evaluation with recommendations for treatment.
Fax (708) 409-3146