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PROSTATIC
QUESTIONNAIRE
Name:
Date:
Take this quiz to help you and your doctor decide whether you could
benefit from treatment.
Please circle the answer
that best represents your response to each of the
following questions.
The questions are designed to gauge the severity
of any symptoms you may be experiencing.
Scores
:
0 - Not
at all
1 -
Less than 1 time in 5
2 -
Less than half the time
3 -
About half the time
4 -
More than half the time
5 -
Almost always
QUESTIONS
-
1. INCOMPLETE EMPTYING
Over the past month, how often have you had a sensation of not emptying your bladder
completely after you have finished urinating?
Score
= O 1 2
3 4 5
2 .FREQUENCY
Over the past month, how often have you had to urinate again less than 2 hours after you have
finished urinating?
Score = O 1 2 3 4 5
3. INTERMITTENCY
Over the past month, how often have you found you stopped and started again several tiles
when you urinated?
Score = O 1 2 3 4 5
4. URGENCY
Over the past month, how often have you found it difficult to postpone urination?
Score = O 1 2 3 4 5
5 .WEAK STREAM
Over the past month, how often have you had a weak urinary stream?
Score = O 1 2 3 4 5
6 .STRAINING
Over the past month, how often have you had to push or strain to begin urination?
Score = O 1 2 3 4 5
7 .NOCTURIA
Over the past month, how many tiles did you most typically get up to urinate from the
tile you went to bed at night until the time you got up in the morning?
Score = O 1 2 3 4 5
Your Total Score
is calculated by adding up the numbers you circled above.
Total
Score = ______
QUALITY OF LIFE DUE TO URINARY SYMPTOMS
If you were to spend the rest of your life with your urinary condition the way it is
now, how would you feel about that?
0 -
Delighted
1 -
Pleased
2 -
Mostly Satisfied
3 -
Mixed
4 -
Mostly Dissatisfied
5 -
Unhappy
6 -
Terrible
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