• International Prostate Symptom Score (IPSS)

  • Date of Birth*
     / /
  • Today's 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?*
  • Frequency - How often have you had to urinate again less than two hours after you finished urinating?*
  • Intermittency - How often have you found you stopped and started again several times when you urinated?*
  • Urgency - How often have you found it difficult to postpone urination?*
  • Weak stream - How often have you had a weak urinary stream?*
  • Straining - How often have you had to push or strain to begin urination?*
  • 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?*
  • 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?*
  • Have you tried medications to help your symptoms?*
  • Did these medications help your symptoms? (Scale 1-10)*
  • Would you be interested in learning about a minimally invasive option that could allow you to discontinue your BHP medications?*

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