Male Urinary Tract (IPSS) Assessment Form

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

Last Updated: 23/10/2019

YOUR DETAILS

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Date of Birth Required
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URINARY TRACT REVIEW

How often does your bladder not feel empty when finished passing urine? Required
How often do you need to pass urine within 2 hours of last urinating? Required
How often does the flow stop and start when passing urine? Required
How often is it hard to delay passing urine? Required
How often is the flow poor? Required
How often do you need to push or strain to begin? Required
How often do you need to pass urine after going to bed? Required

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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