International Prostate Symptom Score Self Assessment Form Prostate Symptom Score Index Name Email Age Incomplete emptying – Over the past month, how often have you had a sensation of not emptying your bladder completely after urinating? Please select your answer 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 Frequency – Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Please select your answer 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 Intermittency – Over the past month, how often have you found you stopped and started again several times when you urinated? Please select your answer 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 Urgency – Over the last month, how difficult have you found it to postpone urination? Please select your answer 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 Weak Stream – Over the past month, how often have you had a weak urinary stream? Please select your answer 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 Straining – Over the past month, how often have you had to push or strain to begin urination? Please select your answer 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 Nocturia – Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? Please select your answer None 1 time 2 times 3 times 4 times 5 times or more Total IPSS Score – If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Please select your answer Delighted Pleased Mostly Satisfied Mixed: Equally satisfied and dissatisfied Mostly Dissatisfied Unhappy Terrible Total Score : 0-7 mildly symptomatic – should be aware and see your doctor if necessary 8-19 moderately symptomatic – should contact your doctor to prevent any worse symptoms 20-35 severely symptomatic – MUST seek medical help immediately and begin treatment Time’s up Book an Appointment with Us Our state-of-the-art imaging, diagnostic and innovative technology Book Now
