Bladder Symptom Score

Bladder Symptom Score
Please fill out this short questionnaire to help us find out more about any urinary problems you might have.
Name *

First Name Last Name
Date *

Month Day Year
Birthday *

Month Day Year
Phone Number *

Area Code Phone Number
Incomplete Emptying: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? *

0 - Not at all 1 - Less than 1 in 5 times 2 - Less than half the time 3 - About half the time 4 - More than half the time 5 - Almost always
Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? *

0 - Not at all 1 - Less than 1 in 5 times 2 - Less than half the time 3 - About half the time 4 - More than half the time 5 - Almost always
Intermittency: Over the past month, how often have you found you stopped and started again several times when you urinated? *

0 - Not at all 1 - Less than 1 in 5 times 2 - Less than half the time 3 - About half the time 4 - More than half the time 5 - Almost always
Urge to Urinate: Over the past month, how often have you found it difficult to postpone urination? *

0 - Not at all 1 - Less than 1 in 5 times 2 - Less than half the time 3 - About half the time 4 - More than half the time 5 - Almost always
Weak Stream: Over the past month, how often have you had a weak urinary stream? *

0 - Not at all 1 - Less than 1 in 5 times 2 - Less than half the time 3 - About half the time 4 - More than half the time 5 - Almost always
Straining: Over the past month, how often had you had to push or strain to begin urination? *

0 - Not at all 1 - Less than 1 in 5 times 2 - Less than half the time 3 - About half the time 4 - More than half the time 5 - Almost always
Urinating at Night: 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? *

0 - None 1 - One time 2 - Two times 3 - Three Times 4 - Four Times 5 - Five Times
Total *
Symptom Score:
- 1-7, Mild
- 8-19, Moderate
- 20-35, Severe
Quality of Life due to Urinary Symptoms: How would you feel if you had to live with your urinary condition the way it is now (no better, no worse) for the rest of your life?

Delighted Pleased Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrible
Please print your assessment and bring it with you to your appointment.
Should be Empty: