IPSS

International Prostate Symptom Score (IPSS)
Patient Name*
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Over the Past Five Months

On a scale from 0-5

(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
Incomplete emptying - How often have you had the sensation of not emptying your bladder completely after you finished urinating?*

(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
Frequency - How often have you had to urinate again less than two hours after you finished urinating?*

(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
Intermittency - How often have you found you stopped and started again several times when you urinated?*

(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
Urgency - How often have you found it difficult to postpone urination?*

(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
Weak stream - How often have you had a weak urinary stream?*

(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
Straining - How often have you had to push or strain to begin urination?*

(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
Sleeping - 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?*

(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
Total International Prostate Symptom Score*
1- 7 mild symptoms, 8 - 19 moderate symptoms, 20 - 35 severe symptoms Regardless of the score, if your symptoms are bothersome you should notify your doctor.
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?*

(0) Delighted(1) Pleased(2) Mostly Satisfied(3) Mixed(4) Mostly Dissatisfied(5) Unhappy(6) Terrible
Have you tried medications to help your symptoms?*

YesNo
Did these medications help your symptoms? (Scale 1-10)*

1 No relief2345678910 Complete relief
Would you be interested in learning about a minimally invasive option that could allow you to discontinue your BHP medications?*

YesNo
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International Prostate Symptom Score (IPSS)