Male Urinary Tract (IPSS) Assessment Form

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

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Your Details

Name *

First

Last

Date of Birth *

Phone Number

Email Address *

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

you ALSO CONFIRM

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

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