AUA Symptom score (auass and quality of life (qol) AUA Symptom Score (AUASS) Patient Name Date Choose one for each line. Over the past month or so, how often have you had a sensation of not emptying your bladder completely afetre you finished urination? * 0 - Not at all 1 - Less than 1 time in 5 2 - Less than half the time 3 - About half the time 4 - more than half the time 5 - Almost always During the past month or so, how often have you had to urinate again less than two hours after you finished urinating? * 0 - Not at all 1 - Less than 1 time in 5 2 - Less than half the time 3 - About half the time 4 - more than half the time 5 - Almost always During the past month or so, how often have you found you stpped and started again several times when you urinated? * 0 - Not at all 1 - Less than 1 time in 5 2 - Less than half the time 3 - About half the time 4 - more than half the time 5 - Almost always During the past month or so, how often have you found out it difficult to postpone urination? * 0 - Not at all 1 - Less than 1 time in 5 2 - Less than half the time 3 - About half the time 4 - more than half the time 5 - Almost always During the past month or so, how often have you had a weak urinary stream? * 0 - Not at all 1 - Less than 1 time in 5 2 - Less than half the time 3 - About half the time 4 - more than half the time 5 - Almost always During the past month or so, how often have you had to push or strain to begin urination? * 0 - Not at all 1 - Less than 1 time in 5 2 - Less than half the time 3 - About half the time 4 - more than half the time 5 - Almost always During the past month or so, how many times per night did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? * 0 - None 1 - 1 time 2 - 2 times 3 - 3 times 4 - 4 times 5 - 5 or more times Add the score for each item above and write the total * Symptom score: 1 - 7 Mild 8 - 19 Moderate 20 - 35 Severe Quality of Life (QOL) How would you feel if you had to live with your urinary condition the way it is now, no better, no worse, for the rest of your life? * 0 - Delighted 1 - Pleased 2 - Mostly Satisfied 3 - Mixed 4 - Mostly Dissatisfied 5 - Unhappy 6 - Terrible Sexual Health Inventory for Men (SHIM) Patient Instructions Sexual Health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor. Each questions has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one reponse for each question. Over the past 6 months 1. How do you rate your confidence that you could get and keep an erection? 1 - Very Low 2 - Low 3 - Moderate 4 - High 5 - Very High 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? 0 - No sexual activity 1 - Almost never or never 2 - A few times (much less than half the time) 3 - Sometimes (half about the time) 4 - Most times (much more than half the time) 5 - Almost always or always 3. During sexual intercourse, how often were you able to maintain your erection afetr you had penetrated (entered) your partner? 0 - Did not attempt intercourse 1 - Almost never or never 2 - A few times (much less than half the time) 3 - Sometimes (half about the time) 4 - Most times (much more than half the time) 5 - Almost always or always 4. During sexual intercourse, how dificult was it to maintain your erection to completion of intercourse? 0 - Did not attempt intercourse 1 - Extremely difficult 2 - Very difficult 3 - Difficult 4 - Slightly difficult 5 - Not difficult 5. When you attempted sexual intercourse, how often was it satisfactory for you? 0 - Did not attempt intercourse 1 - Almost never or never 2 - A few times (much less than half the time) 3 - Sometimes (about half the time) 4 - Most times (much more than half the time) 5 - Almost always or always Add the numbers corresponding to the questions The sexual Health Inventory for Men: 1 - 7 Severe ED 8 - 11 Moderate ED 12 - 16 Mild to Moderate ED 17 - 21 Mild ED
