BPH Health Assessment Survey
Please complete this survey to help us assess your urinary symptoms and quality of life related to Benign Prostatic Hyperplasia (BPH).
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How often have you experienced the following urinary symptoms in the past month?
*
Rows
Not at all
Rarely (less than 1 in 5 times)
Sometimes (less than half the time)
Often (about half the time or more)
Almost always
Frequent urination during the day
1
2
3
4
5
Urgency to urinate
6
7
8
9
10
Weak urinary stream
11
12
13
14
15
Difficulty starting urination
16
17
18
19
20
Intermittent flow (stopping and starting)
21
22
23
24
25
Feeling of incomplete bladder emptying
26
27
28
29
30
Nocturia (waking up at night to urinate)
31
32
33
34
35
How would you rate the overall impact of your urinary symptoms on your quality of life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Which of the following best describes your current urinary health?
*
No symptoms or problems
Mild symptoms, not bothersome
Moderate symptoms, somewhat bothersome
Severe symptoms, very bothersome
Other
Are you currently taking any medications for urinary symptoms or prostate health?
*
Yes
No
If yes, please list the medications you are taking (optional)
Do you have any of the following medical conditions? (Select all that apply)
Diabetes
High blood pressure
Heart disease
History of urinary tract infections
None of the above
Other
Is there anything else you would like to share about your urinary health or symptoms?
Submit Assessment
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