International Prostatism Symptom Score (IPSS)

First Name *

Last Name *

DOB: *

Gender *

MaleFemaleOther

Name of clinician

Please start typing the name of the Doctor or Nurse Practitioner

Please read each statement and select the statement that best applies and which indicates how much the statement applied to you over the past month. There are no right or wrong answers. Do not spend too much time on any statement.

1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? *

2. Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? *

3. Over the past month, how often have you found you stopped and started again several times when you urinated? *

4. Over the past month, how often have you found it difficult to postpone urination? *

5. Over the past month, how often have you had a weak urinary stream? *

6. Over the past month, how often have you had to push or strain to begin urination? *

7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? *

IPSS ScoreMild: 1-7 Moderate: 8-19 Severe: 20-35

MILD

MODERATE

SEVERE

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? *

D'Silva KA, Dahm P, Wong CL. Does this man with lower urinary tract symptoms have bladder outlet obstruction?: The Rational Clinical Examination: a systematic review. JAMA: the Journal of the American Medical Association 2014 August 6, 312 (5): 535-42