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Valley Medical Practice New Cumnock
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Addaction – East Ayrshire Recovery Service
Arranging or changing your DRS (Diabetic retinopathy screening) appointment
Ayrshire Council on Alcohol
Community Connector
Care equipment and adapting your home
Dumfries House Health and Wellbeing
Living well with pain
Pre-Diabetes/Weight Management
Mindfulness
Think Yourself Calm
Women’s Health – Menopause
Fertility
Get Sleepy
East Ayrshire Citizens Advice Bureau
Mental Health Practitioner
Penumbra – Mental Health Support
Physiotherapy (Musculoskeletal disorders)
Podiatry Services
mPower- Empowering over 65s to live well
Practice Pharmacist
Scotland’s Financial Health Service
Sexual Health Services
Sleep Scotland
Speech and Language Therapist
Stop smoking
Weigh to go Ayrshire
See a Doctor or Healthcare Clinician
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Valley Podiatry
Chronic Medication Service
Dementia Services
Interpreting Service
Get a Sick or Fit Note
Gluten-free Food Service
Hepatitis B Immunisation
Home oxygen treatment
Home Visits
Housebound & Older People
Non NHS Services – Chargeable
Order a Repeat Prescription
Wasted Medications
Antibiotic Use
Patient Transport Service
Pharmacy Collection Service
Register with us as a New Patient
Registration Policy
Temporary Services
Transfer of your GP health records
Services for Carers
Holly Health App
Your Care
Healthy Habit Coaching – Holly Health App
Bereavement
At a Loss
Cruse Bereavement Care Scotland
What to do after Death
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Attention deficit hyperactivity disorder (ADHD)
Autism
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British Deaf Association
Capability Scotland
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Enable Scotland
Hearing Loss
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Sense Scotland
Vision Impairment
Wheelchair users and Disabled People
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Childline
Children’s Health Scotland
Change4Life
ERIC – The Children’s Bowl & Bladder Charity
Getting it right for every child (GIRFEC)
Healthy Start – Vitamins in Scotland
Triple P – Positive Parenting Programme
Your Guide to Coughs, Colds, Earache & Sore Throats for your Child
Vaccination Schedule for Children
General Health Advice
Antibiotic Awareness
When to use Antibiotics
Back problems
Cough? Self-help guide
Diarrhoea and Vomiting – Dos and Don’ts
Falls risk screening
Managing your Infection
Melanoma Action and Support Scotland
Menopause
More about Sprains and Strains
My Live Well with Pain
Scotland’s Health and Care News Channel
Strong painkillers and Driving
Testicular lumps and swellings
Testicular Cancer – Check Yourself
Vitamin B12 or folate deficiency anaemia
Health rights for veterans
Lifestyle Changes
Alcohol & Drug Services
Physical Activity – The Single best Medicine
Social Prescribing
Stop Smoking Service
Weight Management
Obesity
Healthy Eating
Eatwell Guide
Food allergy
Food and Nutrition
Food Standards Scotland
Long Term Conditions
Anticipatory care planning
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Breast Cancer (female)
Dementia
Dementia Care and Support
Dementia with Lewy bodies
Making Space
Diabetes
Type 1 Diabetes
Type 2 Diabetes
Diabetic retinopathy
Epilepsy
High Blood Pressure (Hypertension)
Heart Disease
My Lungs My Life – Inhalers
Osteoarthritis
Prostate Cancer
Self Help 4 Stroke
Transient Ischaemic attack (TIA)
Support and advice for your heart condition
Mental Wellbeing
Anxiety
Good mental health for all
Antidepressants
Bipolar Scotland
Breathing Space – Feeling Low, Anxious or Stressed?
Depression
Feeling down or anxious? Beating the Blues 24/7 can help…
Five steps to mental wellbeing
Health in Mind
Lifelink
Managing emotional effects
Mental Health – General advice
Mental Health & Money Advice
Mind – For better Mental Health
Rethink Mental Illness
SAMH – For Scotland’s Mental Health
Samaritans
SANE
Scottish Mental Health Service for Deaf People
The Scottish Recovery Network
Suicidal?
Pregnancy & Baby
Baby Box
CRY-SIS Helpline
Diagnostic tests in Pregnancy
Newborn Hearing Test
Mid pregnancy scan (fetal anomaly scan)
Postnatal Care
Postnatal Depression
Pregnancy and Baby Payment
Ready Steady Baby!
Women and Families Maternal Mental Health Pledge
Preventative Medicine
Annual Health Check
Flu Vaccination
Pneumococcal vaccine for adults
Screening information for the transgender community
Screening Services
Shingles
Sexual Health & Sexuality
Contraceptive Advice
Missed pills and extra pills
Getting and using Contraception
Free Condoms
Gender Dysphoria
LGBT Helpline Scotland information and support
Sexual Health Services
Sexual Health Scotland
Sexually transmitted disease
Help & Support in your Area
East Ayrshire Council
East Ayrshire Works
Help and Support Organisations
Amina – The Muslim Women’s Resource Centre
Asbestos
Age UK
Chest Heart & Stroke Scotland
MND Scotland
Health Unlocked
MS Society
Other useful links
Orchid – Fighting Male Cancer
Over 60 + or have a Disability? Eligible for free bus travel
Parkinson’s Disease
Problem gambling
Ready Scotland
Same You
Scottish Refugee Council
Shelter – Scotland
Silver Line Scotland
Social Care & Support
Telecare – Try our self check online tool
Turning Point Scotland
Touched by Suicide Scotland
The Pavement
The Brain Tumour Charity
We are with you
Self Help Guides
Palliative Care information
Ayrshire Hospice
Cancer in children and young people
Cancer Support Services
End of Life Care
#hellomynameis
Babies, children and young people
‘ Just in Case ‘ medicines
Questions and concerns about end of life care
Palliative care
Society of Will Writers
Together for Short Lives
Supporting Others
Support for carers in East Ayrshire
Are you a Carer?
Care information Scotland
Carers Scotland
Young People
Bitesize
Information for young people using NHS services
See Me
Quarriers
Sexual Health Services
Teenage Friendly
Think Positive about Student Mental Health
The Mix
Young Scot
Ypeople
Your Record
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Physiotherapist (MSK) Form
Smoking Review Form
Keep us up to date
Upload photos or documents
Change of Contact Details Form
Register as a Carer Form
Register for Online Services Form
Emergency Summary Care Record Opt-out Form
Communication Consent Form
Request a Repeat Prescription
News
Menu
Home
About Us
Contact
Contact Telephone Numbers
Location
Opening hours
What to do when we are closed
Send a Message
Making the most of your Practice
Our Team
Doctors
Advanced Nurse Practitioner (ANP)
Nursing Team
Practice Team
Our Allied Health Professionals
Practice Pharmacy Team
Practice Policies
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Shared Decision Making
Social Media
Unacceptable Actions Policy
Zero Tolerance
Data
eHealth
Freedom of information
How NHS Scotland manages your Data
Patient Record
Accessing your Record
Access for Others
Subject Access Requests (SAR)
Subject Access Request (SAR) – Request your Records
Data Sharing Preferences
Emergency Care Summary Record
Multi-Disciplinary Teams
Organ Donation Scotland
Sharing your information with Others
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access – Guidance
Patient Rights
Patient Choice
Complaints, Compliments & Suggestions
Entitlement to NHS Treatment
Healthcare for refugees, asylum seekers and overseas visitors
NHS Patient Rights
NHS Services – Rights & Responsibilities
NHS Scotland – How it works
Patient Charter leaflet
Patient Rights (Scotland) Act 2011
Patient Advice and Support Service (PASS)
Website
Accessibility
Cookie Policy (UK)
Disclaimer
Copyright
Appointments, Tests & Referrals
Appointments
Book an Appointment
Cancel an Appointment
Extended Opening Hours
Get Immediate Help from Your Pharmacist
Help with your GP Appointment
Your Hospital Appointment – Confirm, Change or Cancel
Self-Referral Services
Addaction – East Ayrshire Recovery Service
Arranging or changing your DRS (Diabetic retinopathy screening) appointment
Ayrshire Council on Alcohol
Community Connector
Care equipment and adapting your home
Dumfries House Health and Wellbeing
Living well with pain
Pre-Diabetes/Weight Management
Mindfulness
Think Yourself Calm
Women’s Health – Menopause
Fertility
Get Sleepy
East Ayrshire Citizens Advice Bureau
Mental Health Practitioner
Penumbra – Mental Health Support
Physiotherapy (Musculoskeletal disorders)
Podiatry Services
mPower- Empowering over 65s to live well
Practice Pharmacist
Scotland’s Financial Health Service
Sexual Health Services
Sleep Scotland
Speech and Language Therapist
Stop smoking
Weigh to go Ayrshire
See a Doctor or Healthcare Clinician
Tests & Investigations
Access Your Test Results
Blood Test-information
Other Common Tests
Urine Tests
Tests and Treatments
X-Rays & Scans
Referral for Further Care
Referral to Hospital by your GP
Who do I See?
Clinics & Services
Clinics
Antenatal Care
Child Health Checks
Diabetes Services & “My Diabetes My Way “
Our Clinics
Travel Clinic & Holiday Vaccinations
Online Services
Practice /Other Services
Valley Podiatry
Chronic Medication Service
Dementia Services
Interpreting Service
Get a Sick or Fit Note
Gluten-free Food Service
Hepatitis B Immunisation
Home oxygen treatment
Home Visits
Housebound & Older People
Non NHS Services – Chargeable
Order a Repeat Prescription
Wasted Medications
Antibiotic Use
Patient Transport Service
Pharmacy Collection Service
Register with us as a New Patient
Registration Policy
Temporary Services
Transfer of your GP health records
Services for Carers
Holly Health App
Your Care
Healthy Habit Coaching – Holly Health App
Bereavement
At a Loss
Cruse Bereavement Care Scotland
What to do after Death
Disability
Attention deficit hyperactivity disorder (ADHD)
Autism
Action on Hearing Loss
British Deaf Association
Capability Scotland
Disability information Scotland
Disability Rights UK
Enable Scotland
Hearing Loss
Learning Disabilities
National Autistic Society
Sense Scotland
Vision Impairment
Wheelchair users and Disabled People
Health & Wellbeing
Children’s Health
Childline
Children’s Health Scotland
Change4Life
ERIC – The Children’s Bowl & Bladder Charity
Getting it right for every child (GIRFEC)
Healthy Start – Vitamins in Scotland
Triple P – Positive Parenting Programme
Your Guide to Coughs, Colds, Earache & Sore Throats for your Child
Vaccination Schedule for Children
General Health Advice
Antibiotic Awareness
When to use Antibiotics
Back problems
Cough? Self-help guide
Diarrhoea and Vomiting – Dos and Don’ts
Falls risk screening
Managing your Infection
Melanoma Action and Support Scotland
Menopause
More about Sprains and Strains
My Live Well with Pain
Scotland’s Health and Care News Channel
Strong painkillers and Driving
Testicular lumps and swellings
Testicular Cancer – Check Yourself
Vitamin B12 or folate deficiency anaemia
Health rights for veterans
Lifestyle Changes
Alcohol & Drug Services
Physical Activity – The Single best Medicine
Social Prescribing
Stop Smoking Service
Weight Management
Obesity
Healthy Eating
Eatwell Guide
Food allergy
Food and Nutrition
Food Standards Scotland
Long Term Conditions
Anticipatory care planning
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Breast Cancer (female)
Dementia
Dementia Care and Support
Dementia with Lewy bodies
Making Space
Diabetes
Type 1 Diabetes
Type 2 Diabetes
Diabetic retinopathy
Epilepsy
High Blood Pressure (Hypertension)
Heart Disease
My Lungs My Life – Inhalers
Osteoarthritis
Prostate Cancer
Self Help 4 Stroke
Transient Ischaemic attack (TIA)
Support and advice for your heart condition
Mental Wellbeing
Anxiety
Good mental health for all
Antidepressants
Bipolar Scotland
Breathing Space – Feeling Low, Anxious or Stressed?
Depression
Feeling down or anxious? Beating the Blues 24/7 can help…
Five steps to mental wellbeing
Health in Mind
Lifelink
Managing emotional effects
Mental Health – General advice
Mental Health & Money Advice
Mind – For better Mental Health
Rethink Mental Illness
SAMH – For Scotland’s Mental Health
Samaritans
SANE
Scottish Mental Health Service for Deaf People
The Scottish Recovery Network
Suicidal?
Pregnancy & Baby
Baby Box
CRY-SIS Helpline
Diagnostic tests in Pregnancy
Newborn Hearing Test
Mid pregnancy scan (fetal anomaly scan)
Postnatal Care
Postnatal Depression
Pregnancy and Baby Payment
Ready Steady Baby!
Women and Families Maternal Mental Health Pledge
Preventative Medicine
Annual Health Check
Flu Vaccination
Pneumococcal vaccine for adults
Screening information for the transgender community
Screening Services
Shingles
Sexual Health & Sexuality
Contraceptive Advice
Missed pills and extra pills
Getting and using Contraception
Free Condoms
Gender Dysphoria
LGBT Helpline Scotland information and support
Sexual Health Services
Sexual Health Scotland
Sexually transmitted disease
Help & Support in your Area
East Ayrshire Council
East Ayrshire Works
Help and Support Organisations
Amina – The Muslim Women’s Resource Centre
Asbestos
Age UK
Chest Heart & Stroke Scotland
MND Scotland
Health Unlocked
MS Society
Other useful links
Orchid – Fighting Male Cancer
Over 60 + or have a Disability? Eligible for free bus travel
Parkinson’s Disease
Problem gambling
Ready Scotland
Same You
Scottish Refugee Council
Shelter – Scotland
Silver Line Scotland
Social Care & Support
Telecare – Try our self check online tool
Turning Point Scotland
Touched by Suicide Scotland
The Pavement
The Brain Tumour Charity
We are with you
Self Help Guides
Palliative Care information
Ayrshire Hospice
Cancer in children and young people
Cancer Support Services
End of Life Care
#hellomynameis
Babies, children and young people
‘ Just in Case ‘ medicines
Questions and concerns about end of life care
Palliative care
Society of Will Writers
Together for Short Lives
Supporting Others
Support for carers in East Ayrshire
Are you a Carer?
Care information Scotland
Carers Scotland
Young People
Bitesize
Information for young people using NHS services
See Me
Quarriers
Sexual Health Services
Teenage Friendly
Think Positive about Student Mental Health
The Mix
Young Scot
Ypeople
Your Record
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Physiotherapist (MSK) Form
Smoking Review Form
Keep us up to date
Upload photos or documents
Change of Contact Details Form
Register as a Carer Form
Register for Online Services Form
Emergency Summary Care Record Opt-out Form
Communication Consent Form
Request a Repeat Prescription
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Male Urinary Tract (IPSS) Review Form
Valley Medical Practice New Cumnock
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Male Urinary Tract (IPSS) Review Form
Male Urinary Tract Review and International Prostatism Symptom Score (IPSS)
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your IPS Score
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you found you stopped and started again several times when you urinated?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you found it difficult to postpone urination?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you had a weak urinary stream?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
Over the past month, how often have you had to push or strain to begin urination?
*
Not at all (0 points)
Less than 1 time in 5 (1 point)
Less than half the time (2 points)
About half the time (3 points)
More than half the time (4 points)
Almost always (5 points)
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?
*
None (0 points)
1 time (1 point)
2 time (2 points)
3 times (3 points)
4 times (4 points)
5 or more times (5 points)
IPSS Score
This is calculated automatically, based on the answers to the review questions.
0-7 Points:
Mild symptoms
8-19 Points:
Moderate Symptoms
20-35 Points:
Severe symptoms
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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