IPSS Questionnaire: Prostate Embolization

📋 IPSS Pre-consultation Questionnaire: Prostate (BPH)

Prostate embolization: IPSS score (International Prostate Symptom Score)

Why complete this questionnaire?
The IPSS is the internationally validated questionnaire used to assess urinary symptoms related to benign prostatic hyperplasia (BPH). It helps our team prepare your consultation as well as possible.

👤 Personal information

Full name *

Date of birth *

Email (to receive a copy)

Referring physician (urologist, GP…)

Planned consultation date

Have you already had a urological work-up?

Yes, complete (PSA + ultrasound + flow rate) Yes, partial No

Most recent PSA (ng/mL) and date

Current prostate medication

Alpha-blockers (tamsulosin, alfuzosin…) 5-alpha-reductase inhibitors (finasteride, dutasteride) None

📊 IPSS score: urinary symptoms

For each of the following 7 questions, indicate how often you had this symptom over the past month.

Question	Never (0)	Less than 1 time in 5 (1)	Less than half the time (2)	About half the time (3)	More than half the time (4)	Almost always (5)

Question 8 (Quality of life): If you were to spend the rest of your life with your urinary symptoms as they are now, how would you feel about it?

Delighted (0)

Pleased (1)

Mostly satisfied (2)

Mixed: neither satisfied nor dissatisfied (3)

Mostly dissatisfied (4)

Unhappy (5)

Terrible (6)

💬 Additional information

Other symptoms or comments

Current medication

📄 This questionnaire is meant to be completed at home, ahead of your consultation. Fill it in, then print it or save it as a PDF and bring it with you on the day of your appointment. Nothing is sent automatically. If you would like to send it in advance, you can email it yourself via Contact us (at your own responsibility).

For Pr Dohan · IR Cochin