• Bladder Symptom Score

  • Please fill out this short questionnaire to help us find out more about any urinary problems you might have.

  • Date*
     - -
  • Birthday*
     - -
  •  -
  • Incomplete Emptying: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?*
  • Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?*
  • Intermittency: Over the past month, how often have you found you stopped and started again several times when you urinated?*
  • Urge to Urinate:​ Over the past month, how often have you found it difficult to postpone urination?*
  • Weak Stream: Over the past month, how often have you had a weak urinary stream?*
  • Straining: Over the past month, how often had you had to push or strain to begin urination?*
  • 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?*

  • 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?

  • Please print your assessment and bring it with you to your appointment.

  •  
  • Should be Empty: