Please select the answer that best describes your response to each question.

 

In the past month:

 
Incomplete Emptying
How often have you had the sensation of not emptying your bladder?
 
 
 
 
 
 
 
 
 
 
 
 

Frequency
How often have you had the sensation of not emptying your bladder?
 
 
 
 
 
 
 
 
 
 
 
 

Intermittency
How often have you found you stopped and started again several times when you urinated?
 
 
 
 
 
 
 
 
 
 
 
 

Urgency
How often have you found it difficult to postpone urination?
 
 
 
 
 
 
 
 
 
 
 
 

Weak stream
How often have you had a weak urinary stream?
 
 
 
 
 
 
 
 
 
 
 
 

Straining
How often have you had to strain to start urination?
 
 
 
 
 
 
 
 
 
 
 
 
 

In the past month:

 
Nocturia
How many times did you typically get up at night to urinate?
 
 
 
 
 
 
 
 
 
 
 
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 759
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.