Male Urinary Tract (IPSS) Review Form

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your IPS Score

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? *

Not at all (0 points)

Less than 1 time in 5 (1 point)

Less than half the time (2 points)

About half the time (3 points)

More than half the time (4 points)

Almost always (5 points)

Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? *

Not at all (0 points)

Less than 1 time in 5 (1 point)

Less than half the time (2 points)

About half the time (3 points)

More than half the time (4 points)

Almost always (5 points)

Over the past month, how often have you found you stopped and started again several times when you urinated? *

Not at all (0 points)

Less than 1 time in 5 (1 point)

Less than half the time (2 points)

About half the time (3 points)

More than half the time (4 points)

Almost always (5 points)

Over the past month, how often have you found it difficult to postpone urination? *

Not at all (0 points)

Less than 1 time in 5 (1 point)

Less than half the time (2 points)

About half the time (3 points)

More than half the time (4 points)

Almost always (5 points)

Over the past month, how often have you had a weak urinary stream? *

Not at all (0 points)

Less than 1 time in 5 (1 point)

Less than half the time (2 points)

About half the time (3 points)

More than half the time (4 points)

Almost always (5 points)

Over the past month, how often have you had to push or strain to begin urination? *

Not at all (0 points)

Less than 1 time in 5 (1 point)

Less than half the time (2 points)

About half the time (3 points)

More than half the time (4 points)

Almost always (5 points)

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? *

None (0 points)

1 time (1 point)

2 time (2 points)

3 times (3 points)

4 times (4 points)

5 or more times (5 points)

IPSS Score

This is calculated automatically, based on the answers to the review questions.

0-7 Points:	Mild symptoms
8-19 Points:	Moderate Symptoms
20-35 Points:	Severe symptoms

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Male Urinary Tract (IPSS) Review Form

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