|
Please answer the following questions about your symptoms.
Write your score for each question at the end of each row. |
||||||||
| Over
the past month, how often have you |
Not
at all |
Less
than 1 time in 5 |
Less
than half the time |
About
half the time |
More
than half the time |
Almost
always |
Your
Score |
|
| 1.
Over the past month, how often have you had a sensation of not emptying
your bladder completely after you finished urinating? |
0 |
1 |
2 |
3 |
4 |
5 |
||
2.
Over the past month, how often have you had to urinate again less than
two hours after you finished urinating? |
0 |
1 |
2 |
3 |
4 |
5 |
||
3.
Over the past month, how often have you stopped and started again several
times when you urinated? |
0 |
1 |
2 |
3 |
4 |
5 |
|
|
4.
Over the past month, how often have you found it difficult to postpone
urination? |
0 |
1 |
2 |
3 |
4 |
5 |
|
|
5.
Over the past month, how often have you had a weak urinary stream? |
0 |
1 |
2 |
3 |
4 |
5 |
|
|
6.
Over the past month, how often have you had to push or strain to begin
urination? |
0 |
1 |
2 |
3 |
4 |
5 |
|
|
|
7. 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 |
1 |
2 |
3 |
4 |
5 |
|
|
| |
|
|
|
|
|
Total |
||
Delighted |
Pleased |
Mostly Satisfied |
Mixed |
Mostly Dis-satisfied |
Unhappy |
Terrible |
Your Score |
|
| Quality of Life due to
Urinary Symptoms If you were to spend the rest of your life with your urinary condition just the way it is now, would would you feel about that? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
|