I-PSS

Your Appointment Date

Your Name *

First Name Middle Name Last Name

Date of Birth *

Today's Date *

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)