Male Urinary Tract (IPSS)

Due to the current crisis we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

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If you have been advised by the surgery to submit Male Urinary Tract (IPSS) review please use this form.

Male Urinary Tract (IPSS)

Male Urinary Tract (IPSS)

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About You

Full Name: *

Date of Birth: *

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Urinary Tract Review

How often does your bladder not feel empty when finished passing urine?

Almost Always

More than half the time

About half the time

Less than half the time

Less than 1 in 5 times

None

How often do you need to pass urine within 2 hours of last urinating?

Almost Always

More than half the time

About half the time

Less than half the time

Less than 1 in 5 times

None

How often does the flow stop and start when passing urine?

Almost Always

More than half the time

About half the time

Less than half the time

Less than 1 in 5 times

None

How often is it hard to delay passing urine?

Almost Always

More than half the time

About half the time

Less than half the time

Less than 1 in 5 times

None

How often is the flow poor?

Almost Always

More than half the time

About half the time

Less than half the time

Less than 1 in 5 times

None

How often do you need to push or strain to begin?

Almost Always

More than half the time

About half the time

Less than half the time

Less than 1 in 5 times

None

How often do you need to pass urine after going to bed?

More than 4

4

3

2

1

None

Is there any other information that you feel the Clinician should know?

*

I confirm that the information provided is accurate to the best of my knowledge