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American Urological Association BPH Symptom Score Index Questionnaire (301897-DT)

American Urological Association BPH Symptom Score Index Questionnaire (301897-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301897-DT (Rev. 12/27/16) AMERICAN UROLOGICAL ASSOCIATION BPH
SYMPTOM SCORE INDEX QUESTIONNAIRE
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN UROLOGICAL ASSOCIATION BPH
SYMPTOM SCORE INDEX QUESTIONNAIRE




Date: __________________________________

Having to urinate more frequently, as well as more urgently, can definitely interrupt the flow of your day. You should know
that frequent urination is often a symptom of benign prostate hyperplasia (BPH), a noncancerous enlargement of the
prostate gland. BPH is a common condition among men over the age of 50. Waking up several times a night to urinate and
having a weaker, slower, or delayed urine stream are other common symptoms.

Circle the number that best applies to you.
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
1. Incomplete Emptying
Over the last month, how often have you had a sensation
of not emptying your bladder completely after you finish
urinating?
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?
0 1 2 3 4 5
3. Intermittency
Over the past month, how often have you stopped and
started again several times when you urinated?
0 1 2 3 4 5
4. Urgency
Over the past month, how often have you found it difficult
to postpone urination?
0 1 2 3 4 5
5. Weak Stream
Over the past month, how often have you had a weak
urinary stream?
0 1 2 3 4 5
6. Straining
Over the past month, how often have you had to push or
strain to begin urination?
0 1 2 3 4 5
None 1 time 2 times 3 times 4 times 5 times
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?
0 1 2 3 4 5

Add the score for each number above, and write the total in the space to the right
SYMPTOM SCORE = 1-7 MILD 8-19 MODERATE 20-35 SEVERE TOTAL ____________

0=DELIGHTED 1=PLEASED 2=MOSTLY SATISFIED 3=MIXED 4=MOSTLY NOT SATISFIED 5=UNHAPPY
8. Quality of life
How would you feel if you had to live with your urinary
condition the way it is now, no better, no worse, for the
rest of your life?
0 1 2 3 4 5








Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM