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

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