| 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 | |
| 1. INCOMPLETE EMPTYING: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
| 2. FREQUENCY: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
| 3. INTERMITTENCY: Over the past month, how often have you found you stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 |
| 4. URGE TO URINATE: Over the past month, how often have you found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| 5. WEAK STREAM: Over the past month, how often have you had a weak urinary stream? | 0 | 1 | 2 | 3 | 4 | 5 |
| 6. STRAINING: Over the past month, how often have you had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| None | 1 time | 2 times | 3 times | 4 times | 5+ times | |
| 7. URINATING AT NIGHT: Over the past month, 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? | 0 | 1 | 2 | 3 | 4 | 5 |
IPSS Score
June 23, 2018
International Prostate Symptom (IPSS) Score
Name __________________________________Date _________________U.H.I.D.No.__________________
Please fill out this short questionnaire to help us find out more about any urinary problems you might have; for questions 1 through 7, circle the number under the column that best describes your situation; for question 6, circle the number in the row which best describes your situation.
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