| Read each question carefully and circle the number of the answer that best describes your own experiences. |
|---|
| 1. During the past month, how often have you felt a strong need to urinate with little or no warning? | 0. Not at all |
| 1. Less than 1 time in 5 |
| 2. Less than half the time |
| 3. About half the time |
| 4. More than half the time |
| 5. Almost always |
| 2. During the past month, have you had to urinate less than two hours after you finished urinating? | 0. Not at all |
| 1. Less than 1 time in 5 |
| 2. Less than half the time |
| 3. About half the time |
| 4. More than half the time |
| 5. Almost always |
| 3. During the past month, how often did you most typically get up at night to urinate? | 0. Not once |
| 1. Once per night |
| 2. Twice per night |
| 3. Three times per night |
| 4. Four times per night |
| 5. Five times or more per night |
| 4. During the past month, have you experienced pain or burning in your bladder? | 0. Not at all |
| 1. A few times |
| 2. Fairly often |
| 3. Usually |
| 4. Almost always |