Patient Self-Assessment 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?

Never
Occasionally
Usually
Always

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.

Never
Occasionally
Usually
Always

8. If you have pain, is it usually...

No Pain
Mild
Moderate
Severe

9. Does your pain bother you?

Never
Occasionally
Usually
Always

10. Do you have urgency after going to the bathroom?
If you do not have urgency please skip the remaining questions.

Never
Occasionally
Usually
Always

11. If you have urgency, is it usually...

No Urgency
Mild
Moderate
Severe

12. Does the urgency bother you?

Never
Occasionally
Usually
Always

Your total:

Score Legend