IPSS Printable Version Prostate Score (IPSS) Prostate Score (IPSS) Please complete this form so that we may asses your prostate symptoms. Patient Name * Date of Birth * Who is your GP? * Mobile number to contact you * INCOMPLETE EMPTYING. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? * 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? * 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 INTERMITENCY. Over the past month, how often have you found you stopped and started again several times when you urinated? * 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? * 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? * 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? * 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, 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? * None Once Twice Thrice Four times Five times! IPSS Score 0-7 : Mild Symptoms 8-19 : Moderate Symptoms 20-35 : Severe Symptoms This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. Consent * I agree to the privacy policy reCAPTCHA If you are human, leave this field blank. Submit
