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Urological Surgeons - Melbourne

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International Prostate Symptom Score

First name*

Last name*

Over the past month:

How often have you had the sensation of not emptying your bladder?*

How often have you had to urinate less than every two hours?*

How often have you found you stopped and started again several times when you urinated?*

How often have you found it difficult to postpone urination?*

How often have you had a weak urinary stream?*

How often have you had to strain to start urination?*

How many times have you typically get up at night to urinate?*

Additionally, this question refers to your perceived quality of life due to urinary symptoms. Please consider your answer.

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?*

Are you aware of any family history of prostate cancer?*

Yes

Have you had a urinary tract infection over the last year?*

Yes

Do you leak urine, or have to wear incontinence pads?*

Yes

Do you have pain when passing urine?*

Yes

Have you had seen blood in your urine in the last year?*

Yes

Do you have any other urinary tract symptoms?

Consulting Locations:

Contact:

All correspondence to:

Curo Medical

PO BOX 4110

Balwyn East 3103

Electronic correspondence for GPs:

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