I-PSS Form

I-PSS
International Prostate Symptom Score (I-PSS)

The International Prostate Symptom Score (I-PSS) is based on the answers to seven questions concerning urinary symptoms and one question concerning the quality of life. Each question concerning urinary symptoms allows the patient to choose one out of six answers indicating increasing severity of the particular symptoms. The answers are assigned points from 0 to 5. The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic).
mm/dd/yyyy
How would you rate your experience in the past month with the following problems?
0: Not at all
1: Less than 5 times
2: Less than half the time
3: About half the time
4: More than half the time
5: Almost always
1. Incomplete Emptying How often have you had the sensation of not emptying your bladder?
2. Frequency How often have you had to urinate less than every two hours?
3. Intermittency How often have you found you stopped and started again several times when you urinated?
4. Urgency How often have you found it difficult to postpone urination?
5. Weak Stream How often have you had a weak stream?
6.Straining How often have you had to strain to start urination?
7. Nocturna How many times did you typically get up at night to urinate?
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?

  1. Delighted
  2. Pleased
  3. Mostly Satisfied
  4. Mixed
  5. Mostly Dissatisfied
  6. Unhappy
  7. Terrible
Your Answer:

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