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