Your Appointment Date
-
Month
-
Day
Year
Your Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Today's Date
*
-
Month
-
Day
Year
Incomplete Emptying: How often have you had the sensation of not emptying your bladder?
*
Not at All (0 Points)
Less than 1 in 5 times (1 Point)
Less Than Half the Time (2 Points)
About Half the Time (3 Points)
More than Half the Time (4 Points)
Almost Always (5 Points)
Frequency: How often have you had to urinate less than every two hours?
*
Not at All (0 Points)
Less than 1 in 5 times (1 Point)
Less Than Half the Time (2 Points)
About Half the Time (3 Points)
More than Half the Time (4 Points)
Almost Always (5 Points)
Intermittency: How often have you found you stopped and started again several times when you urinated?
*
Not at All (0 Points)
Less than 1 in 5 times (1 Point)
Less Than Half the Time (2 Points)
About Half the Time (3 Points)
More than Half the Time (4 Points)
Almost Always (5 Points)
Urgency: How often have you found it difficult to postpone urination?
*
Not at All (0 Points)
Less than 1 in 5 times (1 Point)
Less Than Half the Time (2 Points)
About Half the Time (3 Points)
More than Half the Time (4 Points)
Almost Always (5 Points)
Weak Stream: How often have you had a weak urinary stream?
*
Not at All (0 Points)
Less than 1 in 5 times (1 Point)
Less Than Half the Time (2 Points)
About Half the Time (3 Points)
More than Half the Time (4 Points)
Almost Always (5 Points)
Straining: How often have you had to strain to start urination?
*
Not at All (0 Points)
Less than 1 in 5 times (1 Point)
Less Than Half the Time (2 Points)
About Half the Time (3 Points)
More than Half the Time (4 Points)
Almost Always (5 Points)
Nocturia: How many times did you typically get up at night to urinate?
*
None (0 Points)
1 Time (1 Point)
2 Times (2 Points)
3 Times (3 Points)
4 Times (4 Points)
5 Times (5 Points)
Add the points above to calculate your I-PSS Score
What Does Your Score Mean?
1-7: Mild
8-19: Moderate
20-35: Severe
Quality of Life Due to Urinary Symptoms: 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?
*
Delighted (0 Points)
Pleased (1 Point)
Mostly Satisfied (2 Points)
Mixed (3 Points)
Mostly Dissatisfied (4 Points)
Unhappy (5 Points)
Terrible (6 Points)
Submit
Should be Empty: