Version May 2024
| Questions to be answered | 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 | Your score |
| 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 2. Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 3. Over the past month, how often have you found you stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 4. Over the past month, how often have you found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 5. Over the past month, how often have you had a weak urinary stream? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 6. Over the past month, how often have you had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | 5 | |
| 7. 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? | 0 (none) | 1 (1 time) | 2 (2 times) | 3 (3 times) | 4 (4 times) | 5 (5 or more times) | |
| Sum of numbers (AUA symptom score): | |||||||
| Total score: | |||||||
| 0 to 7: Mild symptoms | |||||||
| 8 to 19: Moderate symptoms | |||||||
| 20 to 35: Severe symptoms | |||||||
| Quality of life due to urinary symptoms | Delighted | Pleased | Mostly satisfied | Mixed - about equally satisfied and unsatisfied | Mostly dissatisfied | Unhappy | Terrible |
| 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? | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
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