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Prostate Symptom Score

This is a form for recording the Prostate Symptom Score. It is a standalone form ie. it doesn't require an image file to be uploaded with it. Contributed by Shelter Lee, Crossroads Family Practice, Chilliwack, BC.

ProstateSymptomScore.html — HTML, 12Kb

File contents

<html>
<title>International Prostate Symptom Score</title>
<head>

<style type="text/css">
p.title{
	text-transform: uppercase;
	font-size: 16;
	font-family: Arial;
	font-weight: bolder;
	text-align: left;
	color: black;
}
p.heading{
	font-size: 12;
	font-family: Arial;
	font-weight: bolder;
	text-align: left;
	vertical-align: top;
	color: black;
}
p.normaltext{
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
}
td.heading1{
	font-size: 12;
	font-family: Arial;
	font-weight: bold;
	text-align: left;
	vertical-align: top;
	color: white;
	background-color:black ;
	border-width: 1;
}
td.QuestionHeading{
	font-size: 12;
	font-family: Arial;
	font-weight: bold;
	text-align: left;
	vertical-align: top;
	color: white;
	background-color: #505050;
	border-width: 1;
}
td.AnswerHeading{
	font-size: 12;
	font-family: Arial;
	font-weight: bold;
	text-align: center;
	vertical-align: top;
	color: white;
	background-color: #505050;
	border-width: 1;
}

tr.odd{
	background-color: #ffffff;
}
tr.even{
	background-color: #dddddd;
}
td.question{
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
	border-width: 1;
}
td.answer{
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: center;
	vertical-align: middle;
	color: black;
	border-width: 1;
}
td.normaltext{
	width: 100%;
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
	background-color: white;
	border-width: 0;
}
input.formtext{
	width: 100%;
	height: 100%;
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
	background-color: white;
	border-width: 1;
	border-style: solid; 
}
textarea.formtext{
	width: 100%;
	height: auto;
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
	background-color: white;
	border-width: 1;
	border-style: solid;
}

</style>

<!-------Script to maximize window on loading----------->
<script language="JavaScript1.2">
<!--
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
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top.window.outerHeight = screen.availHeight;
top.window.outerWidth = screen.availWidth;
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//-->
</script>
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<!-- CSS Script that removes textarea and textbox borders when printing ---(put this inbetween <header></header>)----------------->
<style type="text/css" media="print">
div.DoNotPrint {
	display: none;
}

input.noborder {
	border : 0px;
	background: transparent;
}
textarea.noborder {
	scrollbar-3dlight-color: transparent;
	scrollbar-3dlight-color: transparent;
	scrollbar-arrow-color: transparent;
	scrollbar-base-color: transparent;
	scrollbar-darkshadow-color: transparent;
	scrollbar-face-color: transparent;
	scrollbar-highlight-color: transparent;
	scrollbar-shadow-color: transparent;
	scrollbar-track-color: transparent;
	background: transparent;
	overflow: hidden;
	//scrollbar : none;
	border : 0px;
}
</style>
<!-- ----------------------------------------------------------------------------------------- -->

<script type="text/javascript" language="javascript">
function getCheckedValue(radioObj) {

	if(!radioObj)
		return parseInt(0);
	var radioLength = radioObj.length;
	if(radioLength == undefined)
		if(radioObj.checked)
			return parseInt(radioObj.value);
		else
			return parseInt(value);
	for(var i = 0; i < radioLength; i++) {
		if(radioObj[i].checked) {
			return parseInt(radioObj[i].value);
		}
	}
	
	return parseInt(0);
}

function totalScore(){
	var i = 0;

	i += getCheckedValue(document.FormName.Q1);
	i += getCheckedValue(document.FormName.Q2);
	i += getCheckedValue(document.FormName.Q3);
	i += getCheckedValue(document.FormName.Q4);
	i += getCheckedValue(document.FormName.Q5);
	i += getCheckedValue(document.FormName.Q6);
	i += getCheckedValue(document.FormName.Q7);


	document.FormName.Score.value = i;
	if (i<=7){
		document.getElementById("mild").style.background='yellow';
		document.getElementById("moderate").style.background='white';
		document.getElementById("severe").style.background='white';
	}
	else if (i>=8 && i<=19){
		document.getElementById("mild").style.background='white';
		document.getElementById("moderate").style.background='yellow';
		document.getElementById("severe").style.background='white';
	}
	else{
		document.getElementById("mild").style.background='white';
		document.getElementById("moderate").style.background='white';
		document.getElementById("severe").style.background='yellow';

	}

}
</script>


</head>

<body>
<form method="post" action="" name="FormName">

<p class="title">
	International Prostate Symptom Score (IPSS)
</p>


<div name="demographics">
<table width="100%">
	<tr>
		<td class="heading1" width=25%>Patient name</td>
		<td class="formtext"><input class="formtext" name="PatientName" type="text" oscarDB=patient_name>
	</tr>
	<tr>
		<td class="heading1">Date:</td>
		<td class="formtext"><input class="formtext" name="TodaysDate" type="text" oscarDB=today>
	</tr>
</table>
</div>

<br>

<div name="Questionnaire">
<table width="100%">

	<tr>
		<td class="QuestionHeading" width=40%>OVER THE <u>PAST MONTH</u>:</td>
		<td class="AnswerHeading" width=10%>Not at all (0)</td>
		<td class="AnswerHeading" width=10%>Less than 1 time in 5 (1)</td> 
		<td class="AnswerHeading" width=10%>Less than half the time (2)</td>
		<td class="AnswerHeading" width=10%>About half the time (3) </td>
		<td class="AnswerHeading" width=10%>More than half the time (4) </td>
		<td class="AnswerHeading" width=10%>Almost always (5) </td>
	</tr>
	<tr class="odd">
		<td class="question"><p class="heading">1. Incomplete Emptying</p><p class="normal"> How often have you had a sensation of not emptying your bladder completely after you finish urinating?</p></td>
		<td class="answer"><input type="radio" name="Q1" value="0"></td>
		<td class="answer"><input type="radio" name="Q1" value="1"></td>
		<td class="answer"><input type="radio" name="Q1" value="2"></td>
		<td class="answer"><input type="radio" name="Q1" value="3"></td>
		<td class="answer"><input type="radio" name="Q1" value="4"></td>
		<td class="answer"><input type="radio" name="Q1" value="5"></td>
	</tr>
	<tr class="even">
		<td class="question"><p class="heading">2. Frequency</p><p class="normal">How often have you had to urinate again less than two hours after you finished urinating?</p></td>
		<td class="answer"><input type="radio" name="Q2" value="0"></td>
		<td class="answer"><input type="radio" name="Q2" value="1"></td>
		<td class="answer"><input type="radio" name="Q2" value="2"></td>
		<td class="answer"><input type="radio" name="Q2" value="3"></td>
		<td class="answer"><input type="radio" name="Q2" value="4"></td>
		<td class="answer"><input type="radio" name="Q2" value="5"></td>
	</tr>
	<tr class="odd">
		<td class="question"><p class="heading">3. Intermittency</p><p class="normal">How often have you found you stopped and started again several times when you urinated?</p> </td>
		<td class="answer"><input type="radio" name="Q3" value="0"></td>
		<td class="answer"><input type="radio" name="Q3" value="1"></td>
		<td class="answer"><input type="radio" name="Q3" value="2"></td>
		<td class="answer"><input type="radio" name="Q3" value="3"></td>
		<td class="answer"><input type="radio" name="Q3" value="4"></td>
		<td class="answer"><input type="radio" name="Q3" value="5"></td>
	</tr>
	<tr class="even">
		<td class="question"><p class="heading">4. Urgency</p><p class="normal">How difficult have you found it to postpone urination?</p></td>
		<td class="answer"><input type="radio" name="Q4" value="0"></td>
		<td class="answer"><input type="radio" name="Q4" value="1"></td>
		<td class="answer"><input type="radio" name="Q4" value="2"></td>
		<td class="answer"><input type="radio" name="Q4" value="3"></td>
		<td class="answer"><input type="radio" name="Q4" value="4"></td>
		<td class="answer"><input type="radio" name="Q4" value="5"></td>
	</tr>
	<tr class="odd">
		<td class="question"><p class="heading">5. Weak Stream</p><p class="normal">How often have you had a weak urinary stream?</p></td>
		<td class="answer"><input type="radio" name="Q5" value="0"></td>
		<td class="answer"><input type="radio" name="Q5" value="1"></td>
		<td class="answer"><input type="radio" name="Q5" value="2"></td>
		<td class="answer"><input type="radio" name="Q5" value="3"></td>
		<td class="answer"><input type="radio" name="Q5" value="4"></td>
		<td class="answer"><input type="radio" name="Q5" value="5"></td>
	</tr>
	<tr class="even">
		<td class="question"><p class="heading">6. Straining</p><p class="normal">How often have you had to push or strain to begin urination?</p></td>
		<td class="answer"><input type="radio" name="Q6" value="0"></td>
		<td class="answer"><input type="radio" name="Q6" value="1"></td>
		<td class="answer"><input type="radio" name="Q6" value="2"></td>
		<td class="answer"><input type="radio" name="Q6" value="3"></td>
		<td class="answer"><input type="radio" name="Q6" value="4"></td>
		<td class="answer"><input type="radio" name="Q6" value="5"></td>
	</tr>
	<tr>
		<td class="QuestionHeading"></td>
		<td class="AnswerHeading">None (0)</td>
		<td class="AnswerHeading">1 time (1)</td> 
		<td class="AnswerHeading">2 times (2)</td>
		<td class="AnswerHeading">3 times (3) </td>
		<td class="AnswerHeading">4 times (4) </td>
		<td class="AnswerHeading">5 or more times (5) </td>
	</tr>

	<tr class="odd">
		<td class="question"><p class="heading">7. Nocturia</p><p class="normal">How many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?</p></td>
		<td class="answer"><input type="radio" name="Q7" value="0"></td>
		<td class="answer"><input type="radio" name="Q7" value="1"></td>
		<td class="answer"><input type="radio" name="Q7" value="2"></td>
		<td class="answer"><input type="radio" name="Q7" value="3"></td>
		<td class="answer"><input type="radio" name="Q7" value="4"></td>
		<td class="answer"><input type="radio" name="Q7" value="5"></td>
	</tr>

</table>
<br>
<table>
<tr>
	<td><input type="button" onclick="totalScore()" value="Calculate Total Score"></td>
	<td><input type="text" name="Score" size="10" value=""></td>
</tr>
</table>


<table width="100%">
	<tr>
		<td class="QuestionHeading" width=30%>Quality of life due to urinary symptoms</u>:</td>
		<td class="AnswerHeading" width=10%>Delighted</td>
		<td class="AnswerHeading" width=10%>Pleased</td> 
		<td class="AnswerHeading" width=10%> Mostly satisfied</td>
		<td class="AnswerHeading" width=10%>Mixed - about equally satisifed and dissatisfied</td>
		<td class="AnswerHeading" width=10%>Mostly dissatisfied</td>
		<td class="AnswerHeading" width=10%>Unhappy</td>
		<td class="AnswerHeading" width=10%>Terrible</td>
	</tr>
	<tr class="odd">
		<td class="question"><p class="normal"> If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?</p></td>
		<td class="answer"><input type="radio" name="Q8" value="0"></td>
		<td class="answer"><input type="radio" name="Q8" value="1"></td>
		<td class="answer"><input type="radio" name="Q8" value="2"></td>
		<td class="answer"><input type="radio" name="Q8" value="3"></td>
		<td class="answer"><input type="radio" name="Q8" value="4"></td>
		<td class="answer"><input type="radio" name="Q8" value="5"></td>
		<td class="answer"><input type="radio" name="Q8" value="6"></td>
	</tr>

</table>
</div>


<br>
<br>


<div name="Interpretation" class="DoNotPrint">
<table width=50%>
<tr>
	<td class="heading1" colspan="2">Interpretation</td>
</tr>
<tr id="mild">
	<td>0-7</td>
	<td>Mildly Symptomatic</td>
</tr>
<tr id="moderate">
	<td>8-19</td>
	<td>Moderately Symptomatic</td>
</tr>
<tr id="severe">
	<td>20-35</td>
	<td>Severely Symptomatic</td>
</tr>
</table>

</div>


<br>
<br>

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div name="FunctionButtons" class="DoNotPrint">
<table>
<tr>
	<td class="subjectline">
		Subject: <input name="subject" size="40" type="text">
		<input value="Submit" name="SubmitButton" type="submit">
		<input value="Reset" name="ResetButton" type="reset">
		<input value="Print" name="PrintButton" onclick="javascript:window.print()" type="button">
	</td>
</tr>
</table>
</div>

</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->

</body>
</html>
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