Incomplete Emptying *

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

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Frequency *

How often have you had to urinate more than once every two hours?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Intermittency *

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

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Urgency *

How often have you found it difficult to postpone urination?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Weak Stream *

How often have you had a weak urinary stream?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Straining *

How often have you had to strain to start urination?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Nocturia *

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

None

Once

Twice

Three times

Four times

More than four times

Quality of life due to urinary symptoms *

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

Mostly dissatisfied

Unhappy

Terrible

Name *

First Name

Last Name