Continence Assessment (UDI-6)

3.[CA]Continence_Assessment_(UDI-6)

Resident

Date

Carer

Please circle the numbers that best describe what you are feeling. Use the following as your guide. While you are completing the questionnaire, consider the symptoms you have been experiencing for the last 3 months. Please complete the form in full even if you have not had problems in all areas.

Key:

Not at all - 0

Slightly - 1

Moderately - 2

Greatly - 3

Do you experience any of these symptoms? If so, how much are you bothered by them?

Frequent Urination?

Plan

Urine leakage related to the feeling of urgency?

Plan

Urine leakage related to physical activity, coughing, or sneezing?

Plan

Small amounts of urine leakage?

Plan

Difficulty emptying your bladder?

Plan

Pain or discomfort in the lower abdomen or genital area?

Plan

Total

Results:

0-5 low risk

6-10 moderate risk

11-15 high risk

If you are human, leave this field blank.