| In the past month: | None at all | Less than 1 in 5 times | Less than half the time | About Half the Time | More than Half the time | Almost Always | Your score |
| 1) Incomplete Emptying How often have you had the sensation of not emptying your bladder? | 0 | 1 | 2 | 3 | 4 | 5 |
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| 2) Frequency How often have you had to urinate less than every two hours? | 0 | 1 | 2 | 3 | 4 | 5 |
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| 3) Intermittency How often have you found you stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 |
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| 4) Urgency How often have you found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 |
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| 5) Weak Stream How often have you had a weak urinary stream? | 0 | 1 | 2 | 3 | 4 | 5 |
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| 6) Straining How often have you had to strain to start urination? | 0 | 1 | 2 | 3 | 4 | 5 |
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| None | 1 Time | 2 Times | 3 Times | 4 Times | 5 Times |
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| 7) Nocturia How many times did you typically get up at night to urinate? | 0 | 1 | 2 | 3 | 4 | 5 |
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| Total I-PSS score |
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