Patient Questionnaire: International Prostate Symptom Score (IPSS)

Incomplete emptying - How often have you had the sensation of not emptying your bladder completely after you finish urinating?

Not at all - 0
Less than one time in five - 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 to urinate again less than two hours after you finished urinating?

Not at all - 0
Less than one time in five - 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?

Not at all - 0
Less than one time in five - 1
Less than half the time - 2
About half the time - 3
More than half the time - 4
Almost always - 5

Urgency - How often do you find it difficult to postpone urination?

Not at all - 0
Less than one time in five - 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?

Not at all - 0
Less than one time in five - 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?

Not at all - 0
Less than one time in five - 1
Less than half the time - 2
About half the time - 3
More than half the time - 4
Almost always - 5

Sleeping - How many times 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?

Not at all - 0
Less than one time in five - 1
Less than half the time - 2
About half the time - 3
More than half the time - 4
Almost always - 5

Add your symptom scores from each column

Total Score 0-7 mild symptoms 8-19 moderate symptoms 20-35 severe symptoms Regardless of the score, if your symptoms are bothersome you should notify your doctor.

Quality of life due to urinary symptoms - 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?

Delighted - 0
Pleased- 1
Mostly satisfied - 2
Mixed: Equally satisfied/dissatisfied - 3
Mostly dissatisfied - 4
Unhappy - 5
Terrible - 6

Date

Name

First Last

Phone

Age

Doctor

Primary Care Doctor

Which symptoms best describe you?

Frequent urination - Day, Night, Both
Pain during urination
Difficulty starting a stream/weak flow
Feeling my bladder is not completely empty
Urge to urinate soon after urinating
Urge to urinate soon after urinating

Have you tried any of the following medications to help your symptoms? Check all that apply

Did these medications help your symptoms?

If you stopped taking your medications, tell us why:

Did not help
Side effects
Too expensive
Other

If you had side effects to medications, explain them here.

Using a scale from 1-10 with 10 being very frustrated and 1 being not frustrated, what is your level of frustration with your urinary symptoms?

Do you currently have any problems with sexual function?

Erectile Dysfunction
Ejactulatory Dysfunction
Other

I am interested in learning more about treatment alternatives to medication.

Yes
No

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Patient Questionnaire: International Prostate Symptom Score (IPSS)

Patient Questionnaire: International Prostate Symptom Score (IPSS)

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