The following questionnaire can help you determine how bothersome your urinary symptoms are and whether you should see your doctor9.
  • Check off the statements below that apply to your symptoms and discuss the results with your doctor.

  • You normally have a sensation of not emptying your bladder completely after you have finished urinating

  • You often need to urinate again less then two hours after you have finished urinating

  • You find yourself stopping and starting again after several times when you urinate

  • You find it difficult to postpone urination
  • Your urinary stream is weak

  • You find yourself having to push or strain to begin urination

  • You get up to urinate three or more times from the time you go to bed at night until the time you get up in the morning

  • You go to the bathroom much more than you used to and start to change your routine to accommodate for extra bathroom trips

Disruption Scale

On a scale of 1 to 5, where 1 is “no disruption at all” and 5 is “very severe disruption,” please
rate the severity of your symptoms when answering the following questions.

How disruptive to your daily routine, including your sex life, are your urinary problems? 


                                              1                            3                            5

How disruptive would you find an interruption to a personal event, such as a wedding or graduation, due to your urinary problems?


                                               1                             3                            5

How disruptive would you find an interruption to a professional event such as a business lunch, meeting or seminar?


                                             1                               3                             5

How disruptive to your daily routine would your urinary problems have to be before seeing a doctor about them? 


                                             1                                3                            5

According to a survey by ICR, nearly half (45%) of men over 50 said they would  have to be experiencing urinary problems or complications for several weeks before seeing a doctor.

If you rated your disruption as a three or higher on this scale, you should discuss options with your doctor to reduce your disruptions and get back to your life.

Please download and print. Bring the screening tool and disruption scale to your doctor to discuss during your appointment for an appropriate diagnosis.