I-PSS Form

If you would prefer to download and print a PDF version of this form, please Click Here
First Name*
Last Name*
Email*
Date of Birth*
Patient Instructions
Each question has several possible responses.
Select the number of the response that best describes your own situation.
Please be sure that you select a response for each question.

1. Incomplete Emptying*
In the last month, how often have you had the sensation of not emptying your bladder?
2. Frequency*
In the last month, how often have you had to urinate less than every two hours?
3. Intermittency*
In the last month, how often have you found you stopped and started again several times when you urinated?
4. Urgency*
In the last month, how often have you found it difficult to postpone urination?
5. Weak Stream*
In the last month, how often have you had a weak urinary stream?
6. Straining*
In the last month, how often have you had to strain to start urination?
7. Nocturia*
In the last month, how many times did you typically get up at night to urinate?
Hidden
Your Total IPSS Score is:
Score 1-7 Mild, 8-19 Moderate, 20-35 Severe
Quality of Life Due to Urinary Symptoms*
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?
This information, including the question, structure and completeness of the sample survey, is based on forms and/or scoring systems developed by independent organizations of relevance to the diagnosis and treatment of benign prostatic hyperplasia (BPH). This material is not a substitute for a consultation or physical examination by a physician.
Phone
This field is for validation purposes and should be left unchanged.

5 Things to Do If You’re at Risk for Peripheral Artery Disease