• King's Health Questionnaire

    To be filled out prior to first session and at six month follow up appointment

  • Below are some daily activities that can be affected by bladder problems.  How much does your bladder problem affect you?  Please answer every question by checking the box that applies to you.

  • 3. ROLE LIMITATIONS

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  • 4. PHYSICAL/SOCIAL LIMITATIONS

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  • 5. PERSONAL RELATIONSHIPS

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  • 6. EMOTIONS

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  • 7. SLEEP/ENERGY

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  • 8. Do you do any of the following?  If so how much?

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  • We would like to know what your bladder problems are and how much they affect you.  From the list below please choose only those problems that you have at present.  Leave out those that don't apply to you.

     

    How much do they affect you?

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  • Should be Empty: