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 Name
Last 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?
*
Please Select
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)
Frequency - How often have you had the sensation of not emptying your bladder completely after you finished urinating?
*
Please Select
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)
Intermittency - How often have you found you stopped and started again several times when you urinated?
*
Please Select
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)
Urgency - How often have you found it difficult to postpone urination?
*
Please Select
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)
Weak stream - How often have you had a weak urinary stream?
*
Please Select
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)
Straining - How often have you had to push or strain to begin urination?
*
Please Select
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)
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?
*
Please Select
Not at all (0)
1 time (1)
2 times (2)
3 times (3)
4 times (4)
5 or more times (5)
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?
*
Please Select
Delighted (0)
Pleased (1)
Mostly satisfied (2)
Mixed (3)
Mostly dissatisfied (4)
Unhappy (5)
Terrible (6)
Medications
Have you tried medications to help your symptoms?
*
Yes
No
Did these medications help your symptoms? Select a number between 1 - 10.
*
No Relief
1
2
3
4
5
6
7
8
9
Complete Relief
10
1 is No Relief, 10 is Complete Relief
What medications did you take?
*
Terazosin (Hytrin)
Doxazosin (Cardura)
Tamsulosin (Flomax)
Alfuzosin (Uroxatral)
Silodosin (Rapaflo)
Tadalafil
Finasteride (Proscar)
Dutasteride (Avodart)
Dutasteride and Tamsulosin (Duodart)
Other
What medications are you currently taking?
*
Terazosin (Hytrin)
Doxazosin (Cardura)
Tamsulosin (Flomax)
Alfuzosin (Uroxatral)
Silodosin (Rapaflo)
Tadalafil
Finasteride (Proscar)
Dutasteride (Avodart)
Dutasteride and Tamsulosin (Duodart)
Other
Have you had any operations or surgery on your prostate?
*
Yes
No
How many operations or surgeries have you had on your prostate?
*
1
2
3 or more
Description of operation or surgery
*
Transurethral resection of the prostate (TURP)
Transurethral incision of the prostate (TUIP)
Open prostatectomy
Laparoscopic or Robotic Prostatectomy
Other
Date of operation or surgery
*
-
Month
-
Day
Year
Date
Description of operation or surgery 2
*
Transurethral resection of the prostate (TURP)
Transurethral incision of the prostate (TUIP)
Open prostatectomy
Laparoscopic or Robotic Prostatectomy
Other
Date of operation or surgery 2
*
-
Month
-
Day
Year
Date
Description of operation or surgery 3
*
Transurethral resection of the prostate (TURP)
Transurethral incision of the prostate (TUIP)
Open prostatectomy
Laparoscopic or Robotic Prostatectomy
Other
Date of operation or surgery 3
*
-
Month
-
Day
Year
Date
Please add any comments
*
Submit
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