Urology for Primary Care
 
 

INTERNATIONAL SYMPTOM INDEX FOR BPH

Patient Name:________________________
Date of Visit:___________
Urinary Symptoms
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. Over the past month, how often have you had the sensation that your bladder was not completely empty after you finished urinating? 0 1 2 3 4 5
2. Over the past month, how often have you had to urinate again less than two hours after you last finished urinating? 0 1 2 3 4 5
3. Over the past month, how often have you found you stopped and started again several times while urinating? 0 1 2 3 4 5
4. Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5
5. Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
6. Over the past month, how often have you had to push or strain to begin urinating? 0 1 2 3 4 5
7. Over the last month, how many times did you typically get up at night to urinate, from the time you went to bed until the time you got up in the morning?
  None 1 time 2 times 3 times 4 times 5 or more times
TOTAL AUA Symptom Score = Sum of questions 1 – 7 ___________
QUALITY OF LIFE SYMPTOM SCORE

If you had 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 (about equally satisfied and dissatisfied) Mostly Dissatisfied Unhappy Terrible

From the American Urological Association (AUA) Symptom Index for BPH - Appendix A

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