Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much this bothers them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

Full Name

MM slash DD slash YYYY
How often do you leak urine?
We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)?
Overall, how much does leaking urine interfere with your everyday life? Please choose a number between 0 (not at all) and 10 (a great deal)
When does urine leak? (Please check all that apply to you)