Rate Your BPH Treatment Welcome to your Rate Your BPH Treatment During the last month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? Not at all Less thant 1 in 5 times Less than half the time About half the time More than half the time Almost always None During the last month, how often have you had to urinate again less than two hours after you finished urinating? Not at all Less than 1 in 5 times Less than half the time Almost half the time More than half the time Almost always None During the last month, how often have you found you stopped and started again several times when you urinated? Not at all Less than 1 in 5 times Less than half the time About half the time More than half the time Almost always None During the last month, how often have you found it difficult to postpone urination? Not at all Less than 1 in 5 times Less than half the time About half the time More than half the time Almost always None During the last month, how often have you had a weak urinary stream? Not at all Less than 1 in 5 times Less than half the time About half the time More than half the time Almost always None During the last month, how often have you had to push or strain to begin urination? Not at all Less than 1 in 5 times Less than half the time About half the time More than half the time Almost always None During the last 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? Not at all Less than 1 in 5 times Less than half the time About half the time More than half the time Almost always None How much do you agree or disagree with the following statement? Strongly Disagree Disagree Neutral Agree Strongly Agree None How long have you been on BPH medications? 0-3 months 3-6 months 6-12 months 1 year or more None Since starting your BPH medications, have you experienced intermittent urination (starting & stopping) New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experience painful urination New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced poor stream during urination New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experience unable to completely empty your bladder (feels like there is more even after going to the bathroom) New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced need for frequent urination: day, night or both New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced sudden or strong urge to urinate New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced leakage – urine with little or no warning (sometimes unable to make it to the bathroom in time) New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced nausea New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced headaches New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced dizziness New since starting BPH meds Continuing since starting BPH meds None Since starting your BPH medications, have you experienced decrease or stoppage in ejaculatory fluid New since starting BPH meds Continuing since starting BPH meds None On a scale of 0 to 10, with 0 being no symptom relief and 10 being complete symptom relief, how much symptom relief have these medications provided you? 0 1 2 3 4 5 6 7 8 9 10 None On a scale of 0 to 10, with 0 being no frustration at all and 10 being extremely frustrated, what is your level of frustration with your BPH symptoms? 0 1 2 3 4 5 6 7 8 9 10 None Are you interested in learning about a new therapy to treat your BPH? Yes No None I am completely satisfied with the symptom relief I’m getting with my current BPH symptoms. Strongly Disagree Disagree Neutral Agree Strongly Agree None Strongly Disagree Disagree Neutral Agree Strongly Agree None Strongly Disagree Disagree Neutral Agree Strongly Agree None I do not like the idea of taking daily medications indefinitely to relieve my BPH symptoms. Strongly Disagree Disagree Neutral Agree Strongly Agree None I am currently bothered by one or more of the side effects of BPH medications (such as lowered sexual drive, erection problems, dizziness, low blood pressure, nasal congestion). Strongly Disagree Disagree Neutral Agree Strongly Agree None Time's up
