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Urinary Symptoms During The Past Month

This document contains a men's health assessment questionnaire for a patient. It includes the American Urological Association Symptom Index (AUA-SI) which has 7 questions about urinary symptoms over the past month. Each question is scored from 0 to 5. The total score is calculated and can indicate mild, moderate, or severe symptoms. It also asks how bothersome any urinary trouble has been in the last month.

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MIHAELA
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416 views1 page

Urinary Symptoms During The Past Month

This document contains a men's health assessment questionnaire for a patient. It includes the American Urological Association Symptom Index (AUA-SI) which has 7 questions about urinary symptoms over the past month. Each question is scored from 0 to 5. The total score is calculated and can indicate mild, moderate, or severe symptoms. It also asks how bothersome any urinary trouble has been in the last month.

Uploaded by

MIHAELA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient Name _______________________________________________ Date ______________________

MEN'S HEALTH ASSESSMENT QUESTIONAIRE


American Urological Association Symptom Index (AUA-SI)
Circle the answer that best describes your symptoms
Less than More
Less than About half Almost
Urinary symptoms during the past month Not at all
1 time in 5
half the
the time
than half
Always
time the time
1. How often have you had a sensation of not emptying
0 1 2 3 4 5
your bladder completely?

2. How often did you urinate more than once within a 2-


0 1 2 3 4 5
hour period?

3. How often have you stopped and started several times


0 1 2 3 4 5
while urinating?

4. How often have you had difficulty postponing


0 1 2 3 4 5
urination?

5. How often have you had a weak urinary stream? 0 1 2 3 4 5

6. How often did you strain to begin to urinate? 0 1 2 3 4 5

7. How many times did you get up during the night to


0 1 2 3 4 5
urinate?

Symptom Score: Total Score : _____________


1-7 mild * 8-19 moderate * 20-35 severe
If your score is 8 or above you should see a urologist for
evaluation. Please call Alpine Urology to make an appointment
BOTHER ASSESSMENT QUESTION

Overall, how bothersome has any trouble urination been during the last month?

O Not at all bothersome O Bothers me a little O Bothers me some O Bothers me a lot

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