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Free IPSS Questionnaire, Prostate Symptom Score PDF | Coflow

Written by Coflow | Nov 12, 2026, 2:23:09 AM
Free template

Digital IPSS questionnaire

Send the IPSS questionnaire digitally to your patients. With Coflow, they answer on their phone or computer before their appointment, with no app and no login.

The symptom score is totalled the moment they submit and banded mild, moderate or severe, with quality of life scored on its own. The scores are waiting for you on the task, and responses write back to your practice management system.

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No patient app or login
Scored automatically
Writes back to your PMS

Try the digital IPSS

Coflow forms are flexible and mobile responsive. Patients fill it in on any phone or computer, with no app and no login. Scored forms are scored automatically when the patient submits.

ipss.pdfPage 1 of 2Download

International Prostate Symptom Score (IPSS)

Urinary symptoms and quality of life over the past month

NameDate
Urinary symptoms

The following questions ask about your urinary symptoms over the past month. Please choose the answer that best describes each one.

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

0Not at all1Less than 1 time in 52Less than half the time3About half the time4More than half the time5Almost always

2Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0Not at all1Less than 1 time in 52Less than half the time3About half the time4More than half the time5Almost always

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

0Not at all1Less than 1 time in 52Less than half the time3About half the time4More than half the time5Almost always

4Over the past month, how often have you found it difficult to postpone urination?

0Not at all1Less than 1 time in 52Less than half the time3About half the time4More than half the time5Almost always

5Over the past month, how often have you had a weak urinary stream?

0Not at all1Less than 1 time in 52Less than half the time3About half the time4More than half the time5Almost always

6Over the past month, how often have you had to push or strain to begin urination?

0Not at all1Less than 1 time in 52Less than half the time3About half the time4More than half the time5Almost always

7Over the past 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?

0None11 time22 times33 times44 times55 or more times
Quality of life due to urinary symptoms

8If 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?

0Delighted1Pleased2Mostly satisfied3Mixed4Mostly dissatisfied5Unhappy6Terrible
Barry, M.J. et al. (1992). AUA Symptom Index. J Urol, 148(5), 1549-1557. Quality of life question as printed on the IPSS.Page 1 of 2

Scoring the IPSS

For the practitioner. Detach before handing the questionnaire to a patient.

How to score it
  1. Each answer scores the number circled next to it. No item is reverse scored.
  2. Add up questions 1–7 for the urinary symptoms score (0–35). Find its band in the table further down.
  3. Question 8, quality of life, is scored 0–6 on its own (delighted to terrible). It is never added to the symptom score.
  4. If any question is unanswered, don’t score the form.
Scores
ScaleItemsRangeScoreBand
Urinary symptoms1–70–35
Quality of life80–6—
Bands: urinary symptoms
BandScore
Mild symptoms0–7
Moderate symptoms8–19
Severe symptoms20–35

The IPSS measures the severity of urinary symptoms. It is not a diagnostic tool: read the score alongside your own clinical assessment.

Barry, M.J. et al. (1992). AUA Symptom Index. J Urol, 148(5), 1549-1557. Quality of life question as printed on the IPSS.Page 2 of 2
9:41

IPSS

Preview only. Nothing you choose is saved or sent.

Step 1 of 2

Urinary symptoms

The following questions ask about your urinary symptoms over the past month. Please choose the answer that best describes each one.

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?*
This field is required.
Over the past month, how often have you had to urinate again less than two hours after you finished urinating?*
This field is required.
Over the past month, how often have you found you stopped and started again several times when you urinated?*
This field is required.
Over the past month, how often have you found it difficult to postpone urination?*
This field is required.
Over the past month, how often have you had a weak urinary stream?*
This field is required.
Over the past month, how often have you had to push or strain to begin urination?*
This field is required.
Over the past 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?*
This field is required.

Step 2 of 2

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?*
This field is required.

Form completed

When a patient submits it for real, Coflow shows you the score based on the scoring guidelines you’ve defined.

ScoresWhat your practice sees
Urinary symptoms7 items, score 0–35
  • 0–7Mild symptoms
  • 8–19Moderate symptoms
  • 20–35Severe symptoms
Quality of life1 item, score 0–6
Send it digitally

Send the IPSS digitally

Patients answer on their phone or computer before they arrive, with no app or login. Coflow sends a reminder if they don’t finish, scores it the moment they submit, and files it into your PMS.

  • Scored automatically
  • Automatic reminders
  • Writes back to your PMS
Book a demo

We’ll show you the IPSS in Coflow and set it up with you.

PDF

Start with the free PDF

We’ll email you the printable IPSS and its scoring guide, plus a few ideas for moving your questionnaires online when you’re ready.

Download the free PDF

On its way. Check your inbox, or download it now.

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