IPSS - International prostate symptom score

Name

Date

Symptom score

0 - Not al all,
1 - Less than 1 time in 5,
2 - Less than half the,
3 - Above half the time,
4 - More than half the,
5 - Almost always

Incomplete emptying: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

Frequency: Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

Intermittency: Over the past month, how often have you found you stopped and started again several times when you urinated?

Urgency: Over the last month, how difficult have you found it to postpone urination?

Weak stream: Over the past month, how often have you had a weak urinary stream?

Straining: Over the past month, how often have you had to push or strain to begin urination?

Symptom score

0 - None,
1 - 1 time,
2 - 2 times,
3 - 3 times,
4 - 4 times,
5 - 5 times or more

Nocturia: Over the past month, 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?

Total IPSS score (Add up your scores from the first 7 questions)

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

Quality of life due to urinary symptoms

0 - Delighted,
1 - Pleased,
2 - Mostly satisfied,
3 - Mixed-about equally satisfied and dissatisfied,
4 - Mostly dissatisfied,
5 - Unhappy,
6 - Terrible

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?

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IPSS - International prostate symptom score

Symptom score

0 - Not al all, 1 - Less than 1 time in 5, 2 - Less than half the, 3 - Above half the time, 4 - More than half the, 5 - Almost always

Symptom score

0 - None, 1 - 1 time, 2 - 2 times, 3 - 3 times, 4 - 4 times, 5 - 5 times or more

Quality of life due to urinary symptoms

0 - Delighted, 1 - Pleased, 2 - Mostly satisfied, 3 - Mixed-about equally satisfied and dissatisfied, 4 - Mostly dissatisfied, 5 - Unhappy, 6 - Terrible

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

0 - Not al all,
1 - Less than 1 time in 5,
2 - Less than half the,
3 - Above half the time,
4 - More than half the,
5 - Almost always

0 - None,
1 - 1 time,
2 - 2 times,
3 - 3 times,
4 - 4 times,
5 - 5 times or more

0 - Delighted,
1 - Pleased,
2 - Mostly satisfied,
3 - Mixed-about equally satisfied and dissatisfied,
4 - Mostly dissatisfied,
5 - Unhappy,
6 - Terrible