| No symptoms | Worst symptoms | ||||||||||
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
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| Pain, pressure and discomfort associated with your bladder/prostate and/or pelvic region | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ |
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| Urgency (urge or pressure to urinate) | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ |
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| Frequency of urination | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ |
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| Overall urologic or pelvic pain symptoms | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ |
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| Overall pain symptoms that were not urologic or pelvic pain symptoms (e.g., back pain, headache, etc) | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ | ❑ |
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