Table 2.

International Consultation on Incontinence Questionnaire Urinary Incontinence—Short Form (ICIQ-UI SF)

1. Please write in your date of birth:	□□ □□ □□
	date month year
2. Are you	Female □ Male □
3. How often do you leak urine? (Tick one box)
	never	□	0
	about once a week or less often	□	1
	two or three times a week	□	2
	about once a day	□	3
	several times a day	□	4
	all the time	□	5
4. We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? (Tick one box)
	None	□	0
	a small amount	□	2
	a moderate amount	□	4
	a large amount	□	6
5. Overall, how much does leaking urine interfere with your everyday life?
Please ring a number between 0 (not at all) and 10 (a great deal)
0 1 2 3 4 5 6 7 8 9 10
not at all a great deal
ICIQ score: sum scores 3+4+5	□□
6. When does urine leak? (Please tick all that apply to you)
	never—urine does not leak	□
	leaks before you can get to the toilet	□
	leaks when you cough or sneeze	□
	leaks when you are asleep	□
	leaks when you have finished urinating and are dressed	□
	leaks for no obvious reason	□
	leaks all the time	□