Skip to content
Clinics & Services
Managing Your Health
About Us
Contact
News
Home
Menu
Clinics & Services
Managing Your Health
About Us
Contact
News
Home
Search
Close
01202 680111
Monday 8:30am – 8pm and Tuesday – Friday 8:30am – 6pm
Male Urinary Tract (IPSS) Review Form
Lifeboat Quay Medical Centre
>
Managing Your Health
>
Health Review Forms
>
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.
Send
Health A-Z
Guide to conditions, symptoms & treatments
Health A-Z
Live Well
Advice, tips and tools for health & wellbeing
Live Well
Medicines Guide
How medicine works & possible side effects
Medicines A-Z
Care & Support
Options & where to to go to get the best support
Services directory
English
Afrikaans
Albanian
Amharic
Arabic
Armenian
Azerbaijani
Basque
Belarusian
Bengali
Bosnian
Bulgarian
Catalan
Cebuano
Chichewa
Chinese (Simplified)
Chinese (Traditional)
Corsican
Croatian
Czech
Danish
Dutch
English
Esperanto
Estonian
Filipino
Finnish
French
Frisian
Galician
Georgian
German
Greek
Gujarati
Haitian Creole
Hausa
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Icelandic
Igbo
Indonesian
Irish
Italian
Japanese
Javanese
Kannada
Kazakh
Khmer
Korean
Kurdish (Kurmanji)
Kyrgyz
Lao
Latin
Latvian
Lithuanian
Luxembourgish
Macedonian
Malagasy
Malay
Malayalam
Maltese
Maori
Marathi
Mongolian
Myanmar (Burmese)
Nepali
Norwegian
Pashto
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Samoan
Scottish Gaelic
Serbian
Sesotho
Shona
Sindhi
Sinhala
Slovak
Slovenian
Somali
Spanish
Sundanese
Swahili
Swedish
Tajik
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Yiddish
Yoruba
Zulu