Prostate symptom score
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you found you stopped and started again several times when you urinated?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you found it difficult to postpone urination?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had a weak urinary stream?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had to push or strain to begin urination?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, 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?
Please Select
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Total IPSS Score
0-7 Points: Mild Symptoms
8-19 Points: Moderate Symptoms
20-35 Points: Severe Symptoms
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