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PATIENT FORMS
CONTACT

Name*

Last name*

How often have you had the sensation of not emptying your bladder completely after you finished urinating?*

Not at all (0)

Less than one time in five (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost always (5)

How often have you had to urinate again less than 2 hours after you finished urinating?*

Not at all (0)

Less than one time in five (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost always (5)

How often have you found you stopped and started again several times when you urinated?*

Not at all (0)

Less than one time in five (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost always (5)

How often have you found it difficult to postpone urination?*

Nota at all (0)

Less than one time in five (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost always (5)

How often have you had a weak urinary stream?*

Not at all (0)

Less than one time in five (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost always (5)

How often have you had to push or strain to begin urination?*

Not at all (0)

Less than one time in five (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost always (5)

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)

One time (1)

Two times (2)

Three times (3)

Four times (4)

Five or more times (5)

If you were to spend the rest of your life with your urinary symptoms just the way it is now, how would you feel?*

Delighted

Pleased

Mostly satisfied

Mixed

Mostly dissatisfied

Unhappy

Terrible

Have you tried medications to help your symptoms?*

Yes

What medications have you tried?*

Flomax / Flomaxtra / Tamsulosin

Duodart (Dutasteride & Tamsulosin)

Xatral SR / Alfuzosin

Urorec / Silodosin

Cialis / Tadalafil

Oxytrol / Ditropan / Oxybutinin

Vesicare / Solifenacin

Betmiga / Mirabegron

None

Did these medications help your symptoms?

Answer questions based on your symptoms over the past month. Choose the answer that most closely approximates your belief.

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