Male Urinary Tract (IPSS) Review Form

Email *

Date of Birth *

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

Phone Number *

Your IPSS Score

1. Sensation of incomplete bladder emptyingNot at all (0)Less than 1 in 5 (1)Less than half the time (2)About half the time (3)More than half the time (4)Almost always (5)

2. Urinating again within 2 hoursNot at all (0)Less than 1 in 5 (1)Less than half the time (2)About half the time (3)More than half the time (4)Almost always (5)

3. Stopped and started againNot at all (0)Less than 1 in 5 (1)Less than half the time (2)About half the time (3)More than half the time (4)Almost always (5)

4. Difficulty postponing urinationNot at all (0)Less than 1 in 5 (1)Less than half the time (2)About half the time (3)More than half the time (4)Almost always (5)

5. Weak urinary streamNot at all (0)Less than 1 in 5 (1)Less than half the time (2)About half the time (3)More than half the time (4)Almost always (5)

6. Straining to begin urinationNot at all (0)Less than 1 in 5 (1)Less than half the time (2)About half the time (3)More than half the time (4)Almost always (5)

7. Nocturia (night urination)None (0)1 time (1)2 times (2)3 times (3)4 times (4)5 or more times (5)

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