Appendix 1
 

Dear

We are aware that some of our females experience leakage of urine of some occasions. We would be grateful if you felt able to complete the enclosed questionnaire. The information you give is in complete confidence. We will use this only to identify what kind of problem this poses and to improve future quality of care.

There are no right or wrong answers, and the questionnaire is strictly confidential, so please do not print your name anywhere on the form.

However, if you would rather not complete the questionnaire we will perfectly understand and your treatment and care will not be affected in any way.

Thank you for your help.

Yours sincerely,
 
 
 

Mary                                          Alison                                                 Rebecca
 
 

Please complete every question with your details or tick as appropriate. If you are unsure how to answer any questions, please give the best answer you can. Feel free to add any comments in the spaces available. 
  1. What age are you?

    2. 16 – 20

    21 – 25

    26 – 30

     31 – 35

     36 – 40

     40 and over
     
     

  2. Coughing weakens the muscles that support your bladder.


    3. How much do you cough? (Please tick all that apply)
     

     
    When your chest is good
    When your chest  is bad
    Just with physiotherapy
    
    
    Other times of the day
    
    
    During the night
    
    
    During physical exercise
    
    

     
  3. Pregnancy, as well as childbirth, can affect leakage of urine. Therefore, we would like to know how many pregnancies of more than 24 weeks you have had?


    4. If you have, indicate how many and continue.

    If none please move to question 6.
     
     

  4. What type of delivery did you have? (Please tick)

    5.  
    Normal       Caesarean section         

     
  5. Did you leak urine,   (Please tick)
    6.  
    Before your pregnancyYes      No        
    During your pregnancyYes      No         
    After deliveryYes      No        

     
  6. In the past year have you ever leaked urine more than once or twice? (Please tick)

    7. Yes            No         

    (If no, go to question 15)
     
     

  7. Was this leakage,    (Please tick all that apply)

    8.  
    Only when my chest was bad
    
    Happened when my chest was good or bad
    
    Worse when my chest was bad 
    

     
  8. Which of these symptoms cause leakage of urine?
    9.  (Please tick all that apply)
     
    When your chest is goodWhen your chest  is bad
    Coughing
    Laughing
    Walking
    Lifting 
    When breathless
    Carrying shopping
    Climbing stairs
    Huffing 
    Only with a full bladder
    Deep breathing
    Sneezing
    Moving when lying to sitting
    Moving when sitting to lying
    Performing a blow (spirometry)
    Other (please specify)
___________________________________________________________________________
9. Do you use pads for leakage? (Please tick)
                                                Yes       No    

10 Which of the following best describes the amount of leakage?  (Please tick all that apply)

    When your chest is goodWhen your chest is bad
    A few drops only
    Have to change underwear
    Have to change pad
    Leakage through to over clothes
    Runs down legs
    Empties whole bladder

11. Does leakage of urine affect your ability to carry out the following? (Please tick all that apply)

 
When your chest is good When your chest is bad
Chest physiotherapy
Exertion (eg walking or exercise)
Performing a blow (spirometry)
Shopping
Social activity
Housework
Other (please specify below)
___________________________________________________________________________
 
  1. Do you agree with the statement "the leakage of urine distresses me severely"? (Please tick)
Yes          No         13. Have you ever sought help for leakage of urine? (Please tick)Yes           No          14. We realise that leakage of urine is a very sensitive issue. If you have the problem but have not sought advice, would you help us by ticking as many of the following statements as are appropriate?
    I don’t want to bother anyone
    It is not as serious as my chest disease 
    I am too embarrassed
    It is a normal thing following childbirth
    Other (please specify below)

______________________________________________________________________________________________________________________________________

15. Are you going through or have you been through the menopause (change of life)? (Please tick)

    No
    Currently going through 
    Been through
    Don’t know 


Thank you very much for your time and help. The information given in the questionnaire is confidential and anonymous.
 

When completed please put the questionnaire in the enclosed envelope.


Although the questionnaire is anonymous the CF physiotherapists are very keen to assist any female who suffers from leakage of urine as we are aware of how distressing this must be. Research has shown that for most people, simple exercises will alleviate the problem. It is important to start these exercises early.
 

Would you like us to help you?
Yes       No    
 

If the answer is yes, then please sign below so that we can make contact with you and hand it to one either Mary, Alison or Rebecca. Alternatively you can speak to one of us directly if you prefer.

………………………………………………………Would you prefer help at Wythenshawe or your local hospital?

Wythenshawe        Local Hospital