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01202 680111
Monday 8:30am – 8pm and Tuesday – Friday 8:30am – 6pm
Male Urinary Tract (IPSS) Review Form
Lifeboat Quay Medical Centre
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Male Urinary Tract (IPSS) Review Form
Male Urinary Tract Review and International Prostatism Symptom Score (IPSS)
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm 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
Privacy Policy
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.
*
I consent to the practice collecting and storing my data from this form.
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