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Home
Clinics & Services
Clinics
Annual Health Check
Antenatal Care
Child Health Checks
Contraceptive Advice
Your Contraception Guide
Flu Vaccination Clinic
Long Term Conditions
NHS Health Check aged 40 – 74
Our Clinics
Weight Management
Referral for Further Care
NHS e-Referral Tracking
Referral to Hospital by your GP
Average Referral Waiting Times
Services
Alcohol Withdrawal Symptoms
Alcohol & Drug Services
Ask My GP
Advocacy Service
Cervical Screening
Dementia Services
Diabetes Services
Interpreting Service
Housebound & Older People
Domestic Violence
New Medicine Service (NMS)
Non NHS Services
Occupational Therapy (O.T)
Online Prescription Service
Over 75 Initiative
Patient Transport Service
Pharmacy First
Practice Dispensary Service
Start using GP online Services
Screening Services
Services for Carers
Stop Smoking Service
Managing Your Health
Appointments
Appointment System
Book an Appointment – online
Cancel an Appointment
Get Immediate Help from Your Pharmacist
Get Immediate Help for Minor Injuries
Help with your GP Appointment
NHS 111 online – Get help for your symptoms
Access your Test Results
Antibiotic Awareness
Consult with a Clinician
Diarrhoea and Vomiting – Dos and Don’ts
Get a Sick or Fit Note
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Home Visits
Managing Your Infection
Monitored Dosage System
Register with us as a New Patient
Temporary Services
GP2GP
Registration Policy
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Optician
Hospitals
NHS Out of Hours Services
Pharmacist
Ordering your Medication
Electronic Prescriptions
Request by Patients for Hepatitis B Immunisation
X-Ray?
What is a Blood Test?
Update your Personal Details Forms
Change of Contact Details Form
Register as a Carer Form
Communication Consent Form
Help & Support
Care & Support
Cancer Support Services
Health Unlocked
Together for Short Lives
The Brain Tumour Charity
Age UK
Orchid – Fighting Male Cancer
Are you a Carer ?
Bereavement
Organ Donation
End of Life Care
End of life care
Together for short Lives
Children’s Health
Triple P – Positive Parenting Programme
Change4Life
Your Guide to Coughs, Colds, Earache & Sore Throats for your Child.
Childline
Disability
Contact – For Families with Disabled Children
Vision Impairment
Deaf or Hard of Hearing
Learning Disability
Autism
How to Care for a Disabled Child
SCOPE Equality for Disabled People
Health & Wellbeing
Menopause
Sprains and Strains
More about Sprains and Strains
Food Allergy
Vitamin B12 or folate deficiency anaemia
Healthy Eating
Testicular Cancer – Check Yourself
Physical Activity – The Single best Medicine
Social Prescribing
Help & Support in your Area
Lincolnshire County Council
Louth Area Autism Family Support (LAAFS)
Shine
Lincolnshire Floating Support Service
Long Term Conditions
Asthma
Breast Cancer (female)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Heart Disease
Dementia
Dementia with Lewy bodies
Diabetes
Epilepsy
High Blood Pressure (Hypertension)
Osteoarthritis
Prostate Cancer
Mental Wellbeing
Depression
Mind – For better Mental Health
Rethink Mental Illness
SANE
Time to Change
Making Space
Samaritans
Mental Health helplines
Mental health issues if you’re gay, lesbian or bisexual
Dealing with a Mental Health crisis or emergency
Feeling down or anxious? Beating the Blues 24/7 can help…
Mental Health
Pregnancy & Baby
Maternity Services Locations
Am I Pregnant?
Smoking affects your unborn baby
Postnatal depression
Sexual Health & Sexuality
Maria Stopes UK
Sexually Transmitted Disease
Lincolnshire Sexual Health
Free Condoms
LGBT Foundation
Gender Dysphoria
About Us
Care Quality Commission
Entitlement to NHS Treatment
Friends and Family Test
GP & Medical Student Training
GP Earnings
Lincolnshire East Clinical Commisioning Group
Patient Participation Group
Minutes
Research
Resources
Newsletters
Over The Counter Initiative
Put Patients First: Back General Practice Campaign
What happens when you are referred by your GP to see a Consultant Privately?
The NHS Constitution
Our Team
Doctors
Clinicians
Practice Administration and Reception
Making the Most of your Practice
Practice Policies
Accessibility
The National Care Record Service (NCRS)
Choose if data from your health records is shared for research and planning
Minuteful Kidney Monitoring — Privacy Policy
Access to your Health Records
Accessible Information Standard
Car Parking
Care Data
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Complaints
Confidentiality
Cookie Policy (UK)
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Freedom of Information
General Practice Extraction Service (GPES)
Infection Control Statement
Named GP Policy
NHS Patient Rights
Non-Smoking Premises
Patient Advice
Patient Advice and Liaison Service PALS
Quality Assurance
Safeguarding Children
The Enhanced Data Sharing Model (EDSM)
Your Rights and Responsibilities
Zero Tolerance
Removal of Patients From our List
Sharing your Information with Others
Privacy Policy
Unacceptable Actions Policy
Website Terms and Conditions
Summary Care Record
Contact
Contact Telephone Numbers
Friends & Family Test
Opening Hours
What to do when we are closed
Enhanced Access
Signing Up For Patient Participation Group
Subject Access Request (SAR)
Location
Car Parking
Send a Message
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Male Urinary Tract (IPSS) Review Form
Tasburgh Lodge Surgery
>
Managing Your Health
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Health Review Forms
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Male Urinary Tract (IPSS) Review Form
Male Urinary Tract Review and International Prostatism Symptom Score (IPSS)
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your IPS Score
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you found you stopped and started again several times when you urinated?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you found it difficult to postpone urination?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you had a weak urinary stream?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you had to push or strain to begin urination?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how many times 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?
*
None (0 points)
1 time (1 point)
2 time (2 points)
3 times (3 points)
4 times (4 points)
5 or more times (5 points)
IPSS Score
This is calculated automatically, based on the answers to the review questions.
0-7 Points:
Mild symptoms
8-19 Points:
Moderate Symptoms
20-35 Points:
Severe symptoms
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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