New Patient Medical History Form

Bladder Health Assessment

As men age, it is common to develop prolonged bladder health conditions and to have questions about this important quality of life health condition. Complete this questionnaire to assess your bladder health. If needed, treatments are available for you.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Have you had prostate cancer?*
How long ago did you complete your treatment?
Years

Months
Do you experience urine leakage?*
Which of the following best describe your symptoms? (Please check all that apply.)*

Leakage with little or no warning (sometimes unable to make it to the bathroom in time)Frequent urination (day, night or both)Accidental leakage with physical activity (e.g., exercising)Other
Do you wear pads or diapers or use a urine collection device or a penile clamp? (Please check all that apply.)

PadsDiapersUrine collection devicePenile clamp
How many pads per day?*
How many diapers per day?*
On a scale of 0 to 5, with 0 being no bother and 5 being extreme bothersome, how bothered are you by your bladder control symptoms?*

0

1

2

3

4

5

0 is , 5 is
If you are interested in discussing your assessment results and learning about durable treatment options, call (573) 499-4990 to make an appointment with one of our physicians or select "Yes" below.
Do you want us to contact you about an appointment*
What is your preferred method of contact?*
Please provide any additional information you would like to discuss at your appointment.
Since you do not experience urine leakage, you do not need to complete the rest of this assessment. Please exit this form. If you have other concerns, you can reach us at (573) 499-4990.

Thank you.
Should be Empty:

Bladder Health Assessment