Patient Information And History Form Page 4

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AUA SYMPTOM INDEX FOR BPH
Patient Name___________________________Date of Visit___________________
Urinary symptoms
Not at
Less
Less
About
More
Almost
all
than 5
than
half the
than
always
times
half the
time
half the
time
time
Over the past month, how often have you had
a sensation of not emptying your bladder
completely after having finished urinating?
Over the past month, how often have you had
to urinate again less than two hours after you
had finished urination?
Over the past month, how often have you
found you stopped and started again several
times while urinating?
Over the past month, how often have you
found it difficult to postpone urination?
Over the past month, how often have you had
a weak urinary stream?
Over the past month, how often have you had
to push or strain to begin urination?
Over the last 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 in the morning?
None
1time
2 times
3 times
4 times
5 or more times
TOTAL AUA SYMPTOM SCORE = SUM OF QUESTION 1 - 7________________________
From the American Urological Association
(AUA) Symptoms Index for BPH

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