InstructionsFor each question below, please the answer that bet describes how you feel. Then, click "Calculate" at the bottom of the questionnaire.
1. How many times do you go to the bathroom during the day?
3-6 7-10 11-14 15-19 20+
2. How many times do you go to the bathroom at night?
0 1 2 3 4+
3. If you get up at night to go to the bathroom, does it bother you?
Never Mildly Moderate Severe
4. Are you currently sexually active?
Yes No
5. If you are sexually active do you now have or have you ever had pain or symptoms during or after sexual intercourse?
Never Occasionally Usually Always
6. If you have pain, does it make you avoid sexual intercourse?
7. Do you have pain associated with your bladder or in your pelvis (vagina, lower abdomen, urethra, perineum, testes, or scrotum)? If you do not have pain, please skip question 8.
8. If you have pain, is it usually...
No Pain Mild Moderate Severe
9. Does your pain bother you?
10. Do you have urgency after going to the bathroom? If you do not have urgency please skip the remaining questions.
11. If you have urgency, is it usually...
No Urgency Mild Moderate Severe
12. Does the urgency bother you?
Your total: Score Legend
Your total:
Score Legend
