International Prostate Symptom Score (I-PSS)

International Prostate Symptom Score (I-PSS)

Version 06.08.23
Patient Name:*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

In the past month:*

Rows	Not at All (0)	Less than 1 in 5 Times (1)	Less than Half the Time (2)	About Half the Time (3)	More than Half the Time (4)	Almost Always (5)
1. Incomplete Emptying How often have you had the sensation of not emptying your bladder?
2. Frequency How often have you had to urinate less than every two hours?
3. Intermittency How often have you found you stopped and started again several times when you urinated?
4. Urgency How often have you found it difficult to postpone urination?
5. Weak Stream How often have you had a weak urinary stream?
6. Straining How often have you had to strain to start urination?

Rows	None (0)	1 Time	2 Times	3 Times	4 Times	5 Times
7. Nocturia How many times did you typically get up at night to urinate?

Score: 1-7: Mild 8-19: Moderate 20-35: Severe

Quality of Life Due to Urinary Symptoms*

Rows	Delighted (0)	Pleased (1)	Mostly Satisfied (2)	Mixed (3)	Mostly Dissatisfied (4)	Unhappy (5)	Terrible (6)
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?

Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty: