Actionable Incontinence Survey | The Canadian Continence Foundation
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The Actionable Urinary Function Screening Tool

This screening tool was developed to help people who have bladder problems, including urinary incontinence. If you think you are one of them, this tool may help drive a conversation between you and your health care provider to address the problem sooner.

For the following questions, please select the response which best describes your bladder symptoms over the past 7 DAYS.

1During the day, how often did you feel that you had to urinate right away?
 
2During the day, how strong was the feeling that you needed to urinate right away?
 
3How often have you had urinary accidents/leakage?
 
4On a typical day, how many times did you urinate?
 
5On a typical night, how often did you wake up in the night to urinate?
 


For the following questions, please select the response which best describes impacts from bladder symptoms you may have experienced RECENTLY.

6How much have your activities with friends and family been limited by your bladder problems?
 
7How embarrassed have you been because of your bladder symptoms?
 
8How much has your ability to work (paid or volunteer) outside the home been limited by your bladder problems?
 
Based on your responses, you may need further evaluation of your bladder health. Please discuss your results with your health care provider.

 
Please click here if you would like to find a doctor in your area who specializes in urinary incontinence.

Print your results to bring to your health care professional.

To send a copy of your responses to this survey,
fill out your email address below and click Send.

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