NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)
Males Only
Patient's Name:
*
First Name
Last Name
Today's Date:
Pain or Discomfort
In the last week, have you experienced any pain or discomfort in the following areas?
*
Yes
1
No
0
Area between rectum and testicles (perineum)
Testicles
Tip of the penis (no related to urination)
Below your waist, in your pubic or bladder area
In the last week, have you experienced:
*
Yes
1
No
0
Pain or burning during urination?
Pain or discomfort during or after sexual climax (ejaculation)?
How often have you had pain or discomfort in any of these areas over the last week?
*
0 Never
1 Rarely
2 Sometimes
3 Often
4 Usually
5 Always
Based on the pain scale below, which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?
*
Back
Next
Urination
How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?
*
0 Not at all
1 Less than one time in five
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always
How often have you had to urinate again less than two hours after you finished urinating, over the last week?
*
0 Not at all
1 Less than one time in five
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always
Impact of Symptoms
How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?
*
0 None
1 Only a little
2 Some
3 A lot
How much did you think about your symptoms, over the last week?
*
0 None
1 Only a little
2 Some
3 A lot
Quality of Life
If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?
*
0 Delighted
1 Pleased
2 Mostly satisfied
3 Mixed (about equally satisfied and dissatisfied)
4 Mostly dissatisfied
5 Unhappy
6 Terrible
Please review all questions and make sure you have answered them to the best of your ability before submitting.
Thank you!
Submit
Should be Empty: