Male Urinary Tract (IPSS) Prostate Assessment

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

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number

Email Address (optional)

Which clinician asked you to submit this form?

Dr Jaffrey

Dr Simpson

Dr Barr

Dr Crawley

Dr Khanam

Dr Dallman

Dr Patterson

Nurse Susie Simpson

Other

Please enter details here
Urinary Tract Review

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

5 - Almost Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Less than 1 in 5 times

0 - None

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

5 - Almost Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Less than 1 in 5 times

0 - None

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

5 - Almost Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Less than 1 in 5 times

0 - None

How often is it hard to delay passing urine?

5 - Almost Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Less than 1 in 5 times

0 - None

How often is the flow poor?

5 - Almost Always

4 - More than half the time

3 - About half the time

2 - Less than half the time

1 - Less than 1 in 5 times

0 - None

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

5 - Almost Always

4 - More than half the time

3 - More than half the time

2 - Less than half the time

1 - Less than 1 in 5 times

0 - None

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

5 - 5 or more

4 - 4

3 - 3

2 - 2

1 - 1

0 - None

Total Score (between 0 - 35)

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.

I consent to the practice collecting and storing my data from this form.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Croyard Medical Practice website

Male Urinary Tract (IPSS) Prostate Assessment

Male Urinary Tract (IPSS) Prostate Assessment

Your Details

Urinary Tract Review