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Please complete the questions below by choosing your response level and then putting the corresponding number in the blue box below that choice.i.e. if your answer to question 1 is less than half the time enter the number 2 in the blue box. If it is almost always enter 5 in the blue box. Your scores will total automatically at the bottom. Complete the final question on how you feel by placing an X in the box next to the corresponding response.

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

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
0 1 2 3 4 5
2. Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
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
0 1 2 3 4 5

3. Intermittency: Over the past month, how often have you found that you stopped and started again several times when you urinated?

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
0 1 2 3 4 5
4. Urgency:Over the past month, how often have you found it difficult to postpone urination?
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
0 1 2 3 4 5

5. Weak-stream: Over the past month, how often have you had a weak stream?

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
0 1 2 3 4 5
6. Straining: Over the past month, how often have you had to push or strain to begin urination?
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
0 1 2 3 4 5

7. Nocturia:Over the past month or so, how many times did you get up to urinate from the time you went to bed until the time you got up in the morning?

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
0 1 2 3 4 5

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? Place an X in the box next to the corresponding response.

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