Name:

Date:

Urinary Function

1. Over the past 4 weeks, how often have you leaked urine?

A. Every day B. Once a week C. Less than once a week D. Not at all

2. During the last 4 weeks, which of the following best describes your urinary control?

A. No control whatsoever B. Frequent dribbling C. Occasional dribbling D. Total control

3. During the last 4 weeks, how many pads or adult diapers did you usually use to control leakage?

A. 3 or more pads per day B. 2 pads per day C. 1 pad per day D. No pads

4. During the last 4 weeks, how big of a problem, if any, has dripping urine or wetting your pants been for you?

A. No problem B. Very small problem C. Moderate problem D. Big problem

Urinary Bother

1. Overall, how big of a problem has your urinary function been over the past 4 weeks?

A. No problem B. Very small problem C. Small problem C. Moderate problem D. Big problem

Bowel Function

1. How often have you had rectal urgency (felt like you had to pass stool, but did not) during the last 4 weeks?

A. More than once a day B. About once a day C. More than once a week

D. Not at all E. Rarely or never

2. How much distress have your bowel movements caused you during the last 4 weeks?

A. Severe distress B. Moderate distress C. Little distress D. No distress

3. How often have you had crampy pain in your abdomen or pelvis during the last 4 weeks?

A. Several times a day B. About once a day C. Several times a week

D. About once a week E. About once a month F. Rarely or never

Bowel Bother

1. Overall, how big of a problem have your bowel habits been over the past 4 weeks?
A. No problem B. Very small problem C. Small problem C. Moderate problem D. Big problems

Sexual Function

1. Are you currently using any of the following on a regular basis to assist your ability to have sexual intercourse? (Please check all devices that you are using)

A. Viagra, Levitra, Cialis B. Penile injections C. Suction Devices D. Penile Implant

2. During the last 4 weeks, how would you rate your ability to have erections?

A. Very poor B. Poor C. Fair D. Good D. Very good

3. During the last 4 weeks, how would you rate your ability to reach orgasm?

A. Very poor B. Poor C. Fair D. Good D. Very good

4. During the last 4 weeks, how would you describe the usual quality of your erections?

A. Not at all B. Not firm enough for any sexual activity C. Firm enough for masturbation or foreplay only

D. Firm enough for intercourse

5. During the last 4 weeks, how would you describe the frequecny of your erections?

A. I have never had an erection when I wanted one B. I had an erection less than half of the time I wanted one

C. I had an erection about half of the time I wanted one D. I had an erection more than half of the time I wanted one

E. I had an erection whenever I wanted one

6. Overall, how would you rate your ability to function sexually during the last 4 weeks?

A. Very poor B. Poor C. Fair D. Good D. Very good

Sexual Bother

1. Overall, how big of a problem has getting and maintaining an erection been for you during the last 4 weeks?

A. No problem B. Very small problem C. Small problem D. Moderate problem E. Big problem