YOUR UROLOGIST
YOUR PERSONAL DETAILS
INCOMPLETE EMPTYING Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?* None at all | Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 | Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time | About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time | More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time | Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
FREQUENCY Over the past month, how often have you had to urinate again less than two hours after you finished urinating?* None at all | Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 | Less than half the time |
About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time | About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time | More than half the time |
Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time | Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost Always
INTERMITTENCY Over the past month, how often have you found you stopped and started again several times when you urinated?* None at all | Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 | Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time | About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time | More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time | Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
URGENCY Over the last month, how difficult have you found it to postpone urination?* None at all | Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 | Less than half the time |
About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time | About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time | More than half the time |
Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time | Almost Always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost Always
WEAK STREAM Over the past month, how often have you had a weak urinary stream?* None at all | Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 | Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time | About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time | More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time | Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
STRAINING Over the past month, how often have you had to push or strain to begin urination?* None at all | Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost Always
None at all |
Less than 1 time in 5 | Less than half the time |
About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time | About half the time |
More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time | More than half the time |
Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time | Almost always
None at all |
Less than 1 time in 5 |
Less than half the time |
About half the time |
More than half the time |
Almost always
NOCTURIA Over the past month, how many times per night did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?* None | 1 time |
2 times |
3 times |
4 times |
5 or more times
None |
1 time | 2 times |
3 times |
4 times |
5 or more times
None |
1 time |
2 times | 3 times |
4 times |
5 or more times
None |
1 time |
2 times |
3 times | 4 times |
5 or more times
None |
1 time |
2 times |
3 times |
4 times | 5 or more times
None |
1 time |
2 times |
3 times |
4 times |
5 or more times
TOTAL I-PSS SCORE 0-7 Mildly Symptomatic
8-19 Moderately Symptomatic
20-35 Severely Symptomatic
0-7 Mildly Symptomatic8-19 Moderately Symptomatic
0-7 Mildly Symptomatic20-35 Severely Symptomatic
QUALITY OF LIFE DUE TO URINARY SYMPTOMS If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?* Delighted | Pleased |
Mostly satisfied |
Mixed, about equally |
Mostly dissatisfied |
Unhappy |
Terrible
Delighted |
Pleased | Mostly satisfied |
Mixed, about equally |
Mostly dissatisfied |
Unhappy |
Terrible
Delighted |
Pleased |
Mostly satisfied | Mixed, about equally |
Mostly dissatisfied |
Unhappy |
Terrible
Delighted |
Pleased |
Mostly satisfied |
Mixed, about equally | Mostly dissatisfied |
Unhappy |
Terrible
Delighted |
Pleased |
Mostly satisfied |
Mixed, about equally |
Mostly dissatisfied | Unhappy |
Terrible
Delighted |
Pleased |
Mostly satisfied |
Mixed, about equally |
Mostly dissatisfied |
Unhappy | Terrible
Delighted |
Pleased |
Mostly satisfied |
Mixed, about equally |
Mostly dissatisfied |
Unhappy |
Terrible
