. Patient Name:________________________________ Date of Birth:_______________ Date Completed_____________ Less than Less than About More than Not at Almost In the past month 1 in 5 half the half the half the Your score all always times time time time Incomplete Emptying: How often have you had the sensation of not emptying 0 1 2 3 4 5 your bladder? Frequency: How often have you had to 0 1 2 3 4 5 urinate less than two hours? Intermittency: How often have you found you stopped and started 0 1 2 3 4 5 again several times while urinating? Urgency: How often have you found it 0 1 2 3 4 5 difficult to postpone urination? Weak Stream: How often have you had a 0 1 2 3 4 5 weak urinary stream? Straining: How often have you had to 0 1 2 3 4 5 strain to start urination? None 1 time 2 times 3 times 4 times 5 times Nocturia: How many times do you 0 1 2 3 4 5 typically get up at night to urinate? Total I-PSS Score Score: 1-7: Mild 8-19: Moderate 20-35: Severe Quality of life Due to Mostly Mostly Delighted Pleased Mixed Unhappy Terrible Urinary Symptoms Satisfied Dissatisfied If you were to spend the rest of your life with your urinary condition just the 0 1 2 3 4 5 6 way it is now, how would you feel about that?
. In the past month Not at all Less than 1 in 5 times Less than half the time About half the time More than half the time Almost always Your score Incomplete Emptying: How often have you had the sensation of not emptying your bladder? 0 1 2 3 4 5 Frequency: How often have you had to urinate less than two hours? 0 1 2 3 4 5 Intermittency: How often have you found you stopped and started again several times while urinating? 0 1 2 3 4 5 Urgency: How often have you found it difficult to postpone urination? 0 1 2 3 4 5 Weak Stream: How often have you had a weak urinary stream? 0 1 2 3 4 5 Straining: How often have you had to strain to start urination? 0 1 2 3 4 5 None 1 time 2 times 3 times 4 times 5 times Nocturia: How many times do you typically get up at night to urinate? 0 1 2 3 4 5 Total I-PSS Score Patient Name:________________________________ Date of Birth:_______________ Date Completed_____________ Score: 1-7: Mild 8-19: Moderate 20-35: Severe Quality of life Due to Urinary Symptoms Delighted Pleased Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrible 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? 0 1 2 3 4 5 6
3International%20Prostate%20Symptom%20Score%202.docx