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 NameLast Name
Date*

MonthDayYear
Birthday*

MonthDayYear
Phone Number*

Area CodePhone 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 all1 - Less than 1 in 5 times2 - Less than half the time3 - About half the time4 - More than half the time5 - 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 all1 - Less than 1 in 5 times2 - Less than half the time3 - About half the time4 - More than half the time5 - 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 all1 - Less than 1 in 5 times2 - Less than half the time3 - About half the time4 - More than half the time5 - Almost always
Urge to Urinate: Over the past month, how often have you found it difficult to postpone urination?*

0 - Not at all1 - Less than 1 in 5 times2 - Less than half the time3 - About half the time4 - More than half the time5 - Almost always
Weak Stream: Over the past month, how often have you had a weak urinary stream?*

0 - Not at all1 - Less than 1 in 5 times2 - Less than half the time3 - About half the time4 - More than half the time5 - Almost always
Straining: Over the past month, how often had you had to push or strain to begin urination?*

0 - Not at all1 - Less than 1 in 5 times2 - Less than half the time3 - About half the time4 - More than half the time5 - 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 - None1 - One time2 - Two times3 - Three Times4 - Four Times5 - 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?

DelightedPleasedMostly SatisfiedMixedMostly DissatisfiedUnhappyTerrible
Please print your assessment and bring it with you to your appointment.
Should be Empty: