Male Urinary Tract (IPSS) Assessment Form

Male Urinary Tract (IPSS) Assessment Form

If you have been advised by the practice to submit a Male Urinary Tract (IPSS) review, please use this form.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Urinary Tract Review

    How often does your bladder not feel empty when finished passing urine?
    How often do you need to pass urine within 2 hours of last urinating?
    How often does the flow stop and start when passing urine?
    How often is it hard to delay passing urine?
    How often is the flow poor?
    How often do you need to push or strain to begin?
    How often do you need to pass urine after going to bed?
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
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Page last reviewed: 17 October 2022
Page created: 04 March 2026