Dr Will Ormiston - IPSS and QoL Questionnaries

International Prostate Symptom Score (IPSS) and Quality of Life (QoL) Questionnaires

Please take a moment to fill out this survey. Answering these questions will help Dr Will Ormiston screen, track your symptoms, and provide an individualised treatment plan.
Patient's Full Name

First NameLast Name
International Prostate Symptom Score (IPSS) Section

Select the answers that applies to you over the last month.
Urinary Symptoms
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 the sensation of not emptying your bladder completely 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?
Urinary Symptoms Overnight
Sleeping - How many time 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?
IPSS Total Score: 1-7 Mild | 8-19 Moderate | 20-35 Severe
Quality of Life (QoL) Section

Select the answer that apply to you over the last month.
Impact of urinary condition on quality of life - 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?
Medications
Have you tried medications to help your symptoms?
Did these medications help your symptoms? Select a number between 1 - 10.

1

2

3

4

5

6

7

8

9

10

1 is No Relief, 10 is Complete Relief
What medications did you take?

Other
What medications are you currently taking?

Other
Have you had any operations or surgery on your prostate?
How many operations or surgeries have you had on your prostate?
Description of operation or surgery

Other
Date of operation or surgery

MonthDayYear
Date
Description of operation or surgery 2

Other
Date of operation or surgery 2

MonthDayYear
Date
Description of operation or surgery 3

Other
Date of operation or surgery 3

MonthDayYear
Date
Please add any comments
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International Prostate Symptom Score (IPSS) and Quality of Life (QoL) Questionnaires

International Prostate Symptom Score (IPSS) Section

Quality of Life (QoL) Section

Medications