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I WANT TO
WHAT WOULD YOU LIKE TO DO?
Make an Appointment
Pay My Bill
Log into the Patient Portal
Physician Referral Form
Get Telehealth Information
Request Patient Records
Check Medical Records Status
__________________________
FIND PATIENT INFO
New Patient Forms
History and Physical Form
Patient Rights Policy
Make an appointment
Urinary Symptom Assessment
Urinary Symptom Assessment
Name
(Required)
First
Last
Phone Number
(Required)
Email
(Required)
Answer the below questions to the best of your ability.
How often have you had the sensation of not emptying your bladder completely after you finished urinating?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
How often have you found you stopped and started again several times when you urinated?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
How often have you had to urinate again less than two hours after you finished urinating?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
How often have you found it difficult to postpone urinating?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
How often have you had a weak stream?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
How often have you had to push or strain to begin urination?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
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?
(Required)
0 - Not at all
1 - Less than one time in five
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always
Have you tried medications to help your symptoms?
(Required)
Yes
No
If yes, do you feel like the medications helped your symptoms?
(Required)
Yes
No
N/A
Would you be interested in learning about other options to treat your urinary symptoms?
(Required)
Yes
No
Add up your symptom scores (1-7 Mild; 8-19 Moderate; 20-35 Severe)
Score
Comments
This field is for validation purposes and should be left unchanged.
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