| 1. In the last week, have you experienced any pain or discomfort in the following areas? |
Yes |
No |
| Area between rectum and testicles (perineum) |
1 |
0 |
| Testicles |
1 |
0 |
| Tip of the penis (not related to urination) |
1 |
0 |
| Below your waist, in your pubic or bladder area |
1 |
0 |
| 2. In the last week, have you experienced: |
Yes |
No |
| Pain or burning during urination? |
1 |
0 |
| Pain or discomfort during or after sexual climax
(ejaculation)? |
1 |
0 |
| 3. How often have
you had pain or discomfort in any of these areas over the
last week? |
| Never |
0 |
| Rarely |
1 |
| Sometimes |
2 |
| Often |
3 |
| Usually |
4 |
| Always |
5 |
| 4. Which hidden best describes your AVERAGE
pain or discomfort on the days that you had it over the last
week? |
|
|
| 5. How often have
you had a sensation of not emptying your bladder completely
after you finished urinating during the last week? |
| Not at all |
0 |
| Less than 1 time in 5 |
1 |
| Less than half time |
2 |
| About half time |
3 |
| More than half time |
4 |
| Almost Always |
5 |
| 6. How often have
you had to urinate again less than 2 hours after you
finished urinating, over the last week? |
| Not at all |
0 |
| Less than 1 time in 5 |
1 |
| Less than half time |
2 |
| About half time |
3 |
| More than half time |
4 |
| Almost Always |
5 |
| 7. How much have
your symptoms kept you from doing the kinds of things you
would usually do, over the last week? |
| None |
0 |
| Only a little |
1 |
| Some |
2 |
| A lot |
3 |
| 8. How much did you
think about your symptoms during the last week? |
| None |
0 |
| Only a little |
1 |
| Some |
2 |
| A lot |
3 |
| 9. If you were to
spend the rest of your life with your symptoms just the way
they have been during the last week, how would you feel
about that ? |
| Delighted |
0 |
| Pleased |
1 |
| Mostly satisfied |
2 |
| Mixed (about equally satisfied and
dissatisfied) |
3 |
| Mostly dissatisfied |
4 |
| Unhappy |
5 |
| Terrible |
6 |
| Scoring the Symptom Index Domains |
| Pain: Total of items 1 a, 1 b, 1 c, 1 d, 2a,
2b, 3, and 4 |
|
| Urinary symptoms: Total of items 5 and 6 |
|
| Quality of life impact: Total of items 7, 8,
and 9 |
|
| Pain and urinary score: Total of item 1 to 6 |
|
| Total score: |
|
(1) Calculate and report 3 separate scores
(pain, urinary symptoms, and quality of life)
(2) Calculate and report a pain and urinary score (range
0-31), referred to as the "symptom scale score."
- Mild = 0-9,
- moderate = 10-18
- severe = 19-31.
(3) Calculate and report total score (range 0-43), referred
to as the "total score." Assess patients at baseline and
follow them over time using each patient as his own control.
Can also use to compare to "norms" established and
published. |