Incontinence questionnaire : Menopause Matters


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Questionnaires > Urinary incontinence/public toilet use.

Survey on Urinary incontinence/public toilet use

Thank you for your help!

The Questionnaire
1.	Age group	Under 30 31-40 41-50 51-60 Over 60
2.	Menopausal status - If you have had a hysterectomy and so are not having periods, please tick the menopausal status box which you feel best represents your status. If ovaries have been removed, then you are postmenopausal, if ovaries are still present, you can be pre, peri or postmenopausal.	premenopausal - regular periods (if you still have a uterus) and no menopausal symptoms. perimenopausal - at least 1 period in last 12 months but period pattern changing (if you still have a uterus) and/or some menopausal symptoms postmenopausal - no period for at least 12 months (if you still have a uterus)
3.	Where do you live?
4.	Do you suffer from urinary incontinence? If no, skip to Q14.	Yes No
5.	Did your incontinence begin during/after menopause?	Yes No
6.	Has your incontinence worsened going through/after the menopause?	Yes No
7.	Have you sought professional health help?	Yes No
8.	If yes to above - was this help useful?	Yes No
9.	If you have not sought health professional help - why not?	too embarrassed Not enough of a problem - can live with it
19.	Do you suffer from urinary incontinence during sex?	Yes No
11.	Does urinary incontinence affect your:	Work Going out Sexual relationships Confidence Overall health
12.	How does urinary incontinence affect your lifestyle?	Has no effect Stops me going out Strains relationship with my partner Stops me doing what I want to do
13.	Do you wear a pad?	No Sometimes All the time
14.	Do you carry spare clothes with you?	No Sometimes All the time
About public toilets
15.	Do you use public toilets?	Yes No
16.	When you go out do you plan your journey around toilets?	Yes No
17.	If you go to a new area would you look for a toilet?	Yes No
18.	Do you go into shops/cafes/pubs/hotels to use toilets?	Yes No
19.	What is your overall impression of public toilets in the UK?	Unclean Adequate Need improvement

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Questionnaire began 3 September 2009
Page last updated: 3 September 2009