AUA Symptom Score
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Provider Name
Patient Information
*
Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
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December
Birth Day
1
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Birth Year
2021
2020
2019
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1911
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1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
AUA Symptom Score
* Required Information
In the past month:
Incomplete Emptying
*
How often have you had a sensation of not emptying your bladder completely after you finished urinating?
Not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Frequency
*
How often have you had to urinate again less than 2 hours after you finished urinating?
Not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Intermittency
*
How often have you found that you stopped and started again several times when you urinated?
Not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Urgency
*
How often have you found it difficult to postpone urination?
Not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Weak Stream
*
How often have you had a weak urinary stream?
Not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Straining
*
How often have you had to push or strain to begin urination?
Not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Nocturia
*
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?
None
1 time
2 times
3 times
4 times
5 times
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 2759
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.