| Date: | Name: |
Over the past month or so, how often have you:
| Symptom | 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 |
| Had a sensation of not emptying your bladder completely after you finished urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| Had to urinate again less than two hours after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 |
| Found you stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 |
| Found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| Had a weak urinary stream? | 0 | 1 | 2 | 3 | 4 | 5 |
| Had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| Had to usually get up to urinate from the time you went to bed until you got up in the morning? | 0 (none) |
1 (once) |
2 (twice) |
3 (3 times) |
4 (4 times) |
5 (5 times or more) |
Score = sum of answers to questions 1 through 7: ______
>= 8 Moderate symptoms
>= 20 Severe symptoms