OVER THE PAST 2 WEEKS, HAVING TO GET UP AT NIGHT TO URINATE ......... | ||||||
score | 4 | 3 | 2 | 1 | 0 | |
1 | Has made it difficult for me to concentrate the next day | □ Every day | □ Most days | □ Some days | □ Rarely | □ Never |
2 | Has made me feel generally low in energy the next day | □ Every day | □ Most days | □ Some days | □ Rarely | □ Never |
3 | Has required me to nap during the day | □ Every day | □ Most days | □ Some days | □ Rarely | □ Never |
4 | Has made me less productive the next day | □ Every day | □ Most days | □ Some days | □ Rarely | □ Never |
5 | Has caused me to participate less in activities I enjoy | □ Extremely | □ Quite a bit | □ Moderately | □ A little bit | □ Not at all |
6 | Has caused me to be careful about when or how much I drink | □ All the time | □ Most of the time | □ Some of the time | □ Rarely | □ Never |
7 | Has made it difficult for me to get enough sleep at night | □ Every night | □ Most nights | □ Some nights | □ Rarely | □ Never |
OVER THE PAST 2 WEEKS, I HAVE BEEN ......... | ||||||
8 | Concerned that I am disturbing others in the house because of having to get up at night to urinate | □ Extremely | □ Quite a bit | □ Moderately | □ A little bit | □ Not at all |
9 | Preoccupied about having to get up at night to urinate | □ All the time | □ Most of the time | □ Some of the time | □ Rarely | □ Never |
10 | Worried that this condition will get worse in the future | □ Extremely | □ Quite a bit | □ Moderately | □ A little bit | □ Not at all |
11 | Worried that there is no effective treatment for this condition (having to get up at night to urinate) | □ Extremely | □ Quite a bit | □ Moderately | □ A little bit | □ Not at all |
12 | Overall, how bothersome has having to get up at night to urinate been during the past 2 weeks? | |||||
□ Extremely | □ Quite a bit | □ Moderately | □ A little bit | □ Not at all | ||
13 | Overall, I would rate my quality of life to be ..... | |||||
Very good 0 1 2 3 4 5 6 7 8 9 10 Very poor |