IPSS / I-PSS Urinary Symptom Questionnaire

CY Men’s Health Clinic — IPSS / I-PSS Questionnaire

International Prostate Symptom Score style urinary questionnaire for lower urinary tract symptoms, prostate/BPH screening, TRT safety documentation, score interpretation, quality-of-life impact, and chart-ready note generation.

1. Patient Information

Patient Name

Date of Birth

Age

Date

Phone

Preferred Language

Reason for Questionnaire

2. IPSS / I-PSS Symptom Questions

For each question, select the answer that best describes symptoms over the past month. Scores: 0 = none, 5 = almost always.

1. Incomplete Emptying

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

2. Frequency

Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?

3. Intermittency

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

4. Urgency

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

5. Weak Stream

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

6. Straining

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

7. Nocturia

Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

3. Quality of Life Due to Urinary Symptoms

This is scored separately from the main IPSS symptom score.

Quality of Life Question

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

4. Red Flag / Safety Screening

These answers do not affect the IPSS score, but help decide whether additional evaluation or referral may be needed.

Blood in Urine?

Pain or Burning With Urination?

Fever/Chills With Urinary Symptoms?

Unable to Urinate / Retention?

Known Elevated PSA?

History of Prostate Cancer?

Family History of Prostate Cancer?

Currently on TRT?

Currently Taking Prostate Medication?

Additional Urinary / Prostate Notes

5. Score Summary

Click “Calculate Score” or “Generate Note” to calculate IPSS score and review safety flags.

IPSS Total Score / 35

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Severity Category

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Quality of Life Score / 6

6. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus.

Patient Signature Name Printed

Signature Date

Signature Captured?

Sign inside the box above.

7. Generated Chart Note

Use this as a draft. Review clinically before saving in the EHR.