Female NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)

Center for Urologic and Pelvic Pain

Name:


Date:


Pain or Discomfort

1. In the last week, have you experienced any pain or discomfort in the following areas?

a. Area between rectum and vagina (perineum)

YesNo

b. Labia

YesNo

c. Clitoris (not related to urination)

YesNo

d. Below your waist in your pubic area

YesNo

e. Below your waist in your rectal area

YesNo

2. In the last week, have you experienced:

a. Pain or burning during urination?

YesNo

b. Pain or discomfort during or after sexual climax?

YesNo

3. How often have you had pain or discomfort in any of these areas over the last week?

Never
Rarely
Sometimes
Often
Usually
Always

4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?

NO PAIN
012345678910
PAIN AS BAD AS YOU CAN IMAGINE


Urination

5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?

Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always or always

6. How often have you had to urinate again less than two hours after you finished urinating, over the last week?

Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always or always

Impact of Symptoms

7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?

None
Only a little
Some
A lot

8. How much did you think about your symptoms, over the last week?

None
Only a little
Some
A lot

Quality of Life

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
Pleased
Mostly satisfied
Mixed (about equally satisfied and dissatisfied)
Mostly dissatisfied
Unhappy
Terrible

Print Now