ANCZ01 For Prostate Cancer Patients Only Prostate AUA BPH Symptom Score Questionnaire

AUA BPH Symptm Score Questionnaire

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Patient Name*

First NameMiddle NameLast Name
Date of Birth*

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

Not al All (0)Less that 1 in 5 Times (1)Less than Half the Time (2)About Half the Time (3)More than Half the Time (4)Almost Always (5)
2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?*

Not al All (0)Less that 1 in 5 Times (1)Less than Half the Time (2)About Half the Time (3)More than Half the Time (4)Almost Always (5)
3. Over the past month, how often have you stopped and started again several times when you urinated?*

Not al All (0)Less that 1 in 5 Times (1)Less than Half the Time (2)About Half the Time (3)More than Half the Time (4)Almost Always (5)
4. Over the past month, how often have you found it difficult to postpone urination?*

Not al All (0)Less that 1 in 5 Times (1)Less than Half the Time (2)About Half the Time (3)More than Half the Time (4)Almost Always (5)
5. Over the past month, how often have you had a weak urinary stream?*

Not al All (0)Less that 1 in 5 Times (1)Less than Half the Time (2)About Half the Time (3)More than Half the Time (4)Almost Always (5)
6. Over the past month, how often have you had to push or strain to begin urination?*

Not al All (0)Less that 1 in 5 Times (1)Less than Half the Time (2)About Half the Time (3)More than Half the Time (4)Almost Always (5)
7. Over the past month, 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 n the morning?*

None (0)1 Time (1)2 Times (2)3 Times (3)4 Times (4)5 or More Times (5)
Total Symptom Score
Score: 1-7: Mild 8-19: Moderate 20-35: Severe

The possible total runs from 0 to 35 points with higher scores indicating more severe symptoms. Socres less than seven are considered mild and generally do not warrant treatment.
Should be Empty: