1. Do you begin to lose urine as soon as you sense a strong need to use the toilet?
   Yes    No
2. Do you lose urine when you walk or exercise, maybe when laughing or coughing?
   Yes    No
3. Do you ever feel as though your bladder is never totally empty, even after urinating?
   Yes    No
4. Do you spend an unusually long time on the toilet but produce only a weak, dribbling stream of urine?
   Yes    No
5. Do you have problems thinking, moving or communicating that prevent you from reaching a toilet in time?
   Yes    No
6. Do you ever wet yourself without being aware of it?
   Yes    No
7. Do you wet your bed at night?
   Yes    No
8. Have you undergone surgery involving your lower abdomen, your pelvic region or a fractured hip?
   Yes    No
9. Are you pregnant?
   Yes    No
10. Do you have frequent bladder infections?
    Yes    No
11. Do you take any of the following types of medications; diuretics (water pills), sedatives, muscle relaxants, narcotic painkillers, antihistamines, anticholinergics, antipsychotics, antidepressants or calcium channel blockers?
    Yes    No
12. Do you drink two or more caffeinated beverages a day?
    Yes    No
13. Do you have a neurological disorder, such as Parkinson's disease?
    Yes    No
14. Do you have multiple sclerosis?
    Yes    No
15. Do you have Alzheimer's disease?
    Yes    No
16. Do you have an enlarged prostate gland?
    Yes    No
17. Have you suffered a stroke?
    Yes    No

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