Please answer honestly so we can give you the best insights!
Has your urine stream changed?
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No, it’s strong and steady
It’s slower than it used to be
It’s weak, stops and starts, and takes longer than before
Have you noticed discomfort or pain in your lower back, pelvic area, or groin?
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No, I feel fine
Occasionally, but nothing serious
Yes, it’s becoming a constant issue
Do you ever have sudden urges to urinate and struggle to hold it?
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No, I have full control
Sometimes, but I manage
Yes, it’s becoming embarrassing and frustrating
Have you experienced a decrease in sexual performance or interest?
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No, everything is normal
Sometimes, but I haven’t thought much of it
Yes, and it’s affecting my confidence
How often do you wake up at night to pee?
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Rarely, if ever
Sometimes (2-3 times)
Almost every night (4+ times)
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Last Name
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Phone
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Email
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