Male Urinary Tract Assessment Form - Summertown Health Centre

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

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

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Male Urinary Tract (IPSS) Assessment Form

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