AUA Symptom Index / International Prostate Symptom Score (IPSS)

Patient Name: ____________________________ *Date:* ____________

Date of Birth: ____________ *Medical Record #:* ____________

Instructions: The following questions ask about urinary symptoms you may have experienced over the past month. For each question, circle the number that best describes your experience. Please answer every question.

SECTION 1: URINARY SYMPTOMS

1. Incomplete Emptying

Over the past month, how often have you had the sensation of not emptying your bladder completely after you finished urinating?

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
0	1	2	3	4	5

2. Frequency

Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

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
0	1	2	3	4	5

3. Intermittency

Over the past month, how often have you found you stopped and started again several times when you urinated?

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
0	1	2	3	4	5

4. Urgency

Over the past month, how often have you found it difficult to postpone urination?

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
0	1	2	3	4	5

5. Weak Stream

Over the past month, how often have you had a weak urinary stream?

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
0	1	2	3	4	5

6. Straining

Over the past month, how often have you had to push or strain to begin urination?

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
0	1	2	3	4	5

7. Nocturia

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?

None	1 Time	2 Times	3 Times	4 Times	5 or More Times
0	1	2	3	4	5

TOTAL AUA/IPSS SYMPTOM SCORE (Questions 1–7): _______ / 35

SECTION 2: QUALITY OF LIFE DUE TO URINARY SYMPTOMS

8. Quality of Life

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

Delighted	Pleased	Mostly Satisfied	Mixed — About Equally Satisfied and Dissatisfied	Mostly Dissatisfied	Unhappy	Terrible
0	1	2	3	4	5	6

Quality of Life Score: _______ / 6

HOW TO INTERPRET YOUR SCORE

Symptom Score (Questions 1–7):

0–7 = Mild symptoms — Your urinary symptoms are minimal. Routine monitoring is usually sufficient.
8–19 = Moderate symptoms — Your symptoms are noticeable and may benefit from treatment. Discuss options with your doctor.
20–35 = Severe symptoms — Your symptoms significantly affect your daily life. Treatment is usually recommended.

Quality of Life Score (Question 8):

0–1 = Very satisfied with current urinary function
2–3 = Acceptable but could be better
4–6 = Significantly bothered; treatment should be strongly considered

What is a meaningful change?

A decrease of 3 or more points in the symptom score after treatment is generally considered a clinically meaningful improvement.

TRACKING YOUR SCORES OVER TIME

Use this table to record your scores at different visits:

Date	Severity	QoL Score (0–6)
_____	☐ Mild ☐ Moderate ☐ Severe	___
_____	☐ Mild ☐ Moderate ☐ Severe	___
_____	☐ Mild ☐ Moderate ☐ Severe	___
_____	☐ Mild ☐ Moderate ☐ Severe	___
_____	☐ Mild ☐ Moderate ☐ Severe	___

Notes for your doctor: _______________________________________________