This tool is designed to help you assess how your bladder symptoms are affecting your quality of life. Rate the frequency of these 25 effects in the past four weeks to determine the overall relative effect of overactive bladder on your coping, concern, sleep, and social interaction.
During the past 4 weeks, how often have your bladder symptoms...
0 = Not at all
1 = A little bit
2 = Somewhat
3 = Quite a bit
4 = A great deal
5 = A very great deal
Made you carefully plan your commute?
0
1
2
3
4
5
Caused you to feel drowsy or sleepy during the day?
0
1
2
3
4
5
Caused you to plan 'escape routes' to restrooms in public places?
0
1
2
3
4
5
Caused you distress?
0
1
2
3
4
5
Frustrated you?
0
1
2
3
4
5
Made you feel like there is something wrong with you?
0
1
2
3
4
5
Interfered with your ability to get a good night's rest?
0
1
2
3
4
5
Caused you to decrease your physical activities (exercising, sports, etc.)?
0
1
2
3
4
5
Prevented you from feeling rested upon waking in the morning?
0
1
2
3
4
5
Frustrated your family and friends?
0
1
2
3
4
5
Caused you anxiety or worry?
0
1
2
3
4
5
Caused you to stay home more often than you would prefer?
0
1
2
3
4
5
Caused you to adjust your travel plans so that you are always near a restroom?
0
1
2
3
4
5
Made you avoid activities away from restrooms (i.e., walks, running, hiking)?
0
1
2
3
4
5
Made you frustrated or annoyed about the amount of time you spend in the restroom?
0
1
2
3
4
5
Awakened you during sleep?
0
1
2
3
4
5
Made you worry about odor or hygiene?
0
1
2
3
4
5
Made you uncomfortable while traveling with others because of needing to stop for a restroom?
0
1
2
3
4
5
Affected your relationships with family and friends?
0
1
2
3
4
5
Caused you to decrease participating in social gatherings, such as parties or visits with family or friends?
0
1
2
3
4
5
Caused you embarrassment?
0
1
2
3
4
5
Interfered with getting the amount of sleep you needed?
0
1
2
3
4
5
Caused you to have problems with your partner or spouse?
0
1
2
3
4
5
Caused you to plan activities more carefully?
0
1
2
3
4
5
Caused you to locate the closest restroom as soon as you arrive at a place you have never been?
0
1
2
3
4
5
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