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PATIENT INSTRUCTIONS
Each question has several possible responses. Select the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question.
7
Questions
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1
Incomplete Emptying
*
This field is required.
How often have you had the sensation of not emptying your bladder?
0 - Not at all
1 - Less than 1 in 5 times
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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2
Frequency
*
This field is required.
How often have you had to urinate less than every two hours?
0 - Not at all
1 - Less than 1 in 5 times
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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3
Intermittency
*
This field is required.
How often have you found you stopped and started again several times when you urinated?
0 - Not at all
1 - Less than 1 in 5 times
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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4
Urgency
*
This field is required.
How often have you found it difficult to postpone urination?
0 - Not at all
1 - Less than 1 in 5 times
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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5
Weak Stream
*
This field is required.
How often have you had a weak urinary stream?
0 - Not at all
1 - Less than 1 in 5 times
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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6
Straining
*
This field is required.
How often have you had to strain to start urination?
0 - Not at all
1 - Less than 1 in 5 times
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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7
Straining
*
This field is required.
How many times did you typically get up at night to urinate?
0 - None
1 - One time
2 - Two times
3 - Three times
4 - Four times
5 - Five times
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8
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