Male Urinary Tract (IPSS) Assessment Form

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

Please select the practice location most relevant to this Online Form submission:

First Names

Surname

Date of Birth

Telephone Number

Assessment Questions

How often does your bladder not feel empty when finished passing urine?

How often do you need to pass urine within 2 hours of last urinating?

How often does the flow stop and start when passing urine?

How often is it hard to delay passing urine?

How often is the flow poor?

How often do you need to push or strain to begin?

How often do you need to pass urine after going to bed?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Stonecross Surgery • 25 Streetend Road, Chatham, Kent, ME5 0AA.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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