Male Bladder Survey
Patient Information
Name
First Name
Middle Name
Last Name
Date of Birth
SSN
Marital Status
Please Select
Single
Married
Widowed
Separated
Divorced
Permanent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred method of contact for reminder calls
Voicemail
Text
Email
If voicemail, please select preferred number
Primary
Secondary
Race
Please Select
African American
American Indian
Asian
Hispanic
White
Mixed Race
Other
Decline to Report
Ethnicity
Please Select
Hispanic
Non-Hispanic
Decline to Report
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Bladder Survey
How long have you had a bladder problem?
Please Select
Less than 6 months
6-12 months
1-5 years
More than 5 years
How many times do you urinate in a day?
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25+
How often do you urinate during the day?
Please Select
Multiple times per hour
Hourly
Every 1-2 hours
Every 2-3 hours
How many times do you get up at night to urinate?
Please Select
1
2
3
4
5
6
7
8
9
10
On a scale of 0 to 10, how do you describe your urge to urinate?
Please Select
0
1
2
3
4
5
6
7
8
9
10
(0 = no hurry, 10 = get out of my way)
Do you leak urine?
Please Select
Yes
No
How many bladder leaks do you have per day?
Please Select
1
2
3
4
5
6
7
8
9
10+
Do you wear a pad?
Please Select
Yes
No
How many pads do you use per day?
Please Select
1
2
3
4
5
6
7
8
9
10+
Do you wear diapers?
Please Select
Yes
No
How many diapers do you use per day?
Please Select
1
2
3
4
5
6
7
8
9
10+
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Bladder problems can have a negative impact on your quality of life. Check ALL boxes that apply.
Must avoid certain activities
Is a source of shame
Prevents a good night’s sleep
Causes me emotional distress
Interferes with work
Affects my relationships
Fear of leaving home
Interferes with intimacy
Restricts my independence
Fear of an odor
Difficult to travel
Often carry extra clothing
Wear dark clothing to hide accidents
Produces worry and frustration
Bladder problems disrupt my daily activities, including:
Increasingly embarrassing
Going grocery shopping
Going out with family or friends
Exercising regularly
Attending church or family events
Spending quality time with grandkids
Have you previously discussed your bladder symptoms with any of the following? Check ALL boxes that apply
Nurse Practitioner
Primary Care Provider
Urologist
No
What is the largest amount you have urinated at one time? Was it at least:
½ cup (about 4 ounces or 100 ml)
¾ cup (about 6 ounces or 150 ml)
1 cup (about 8 ounces or 200 ml)
Have you tried any of the following bladder control strategies? Check ALL boxes that apply
Resisting/ignoring the urge to urinate
Reducing alcohol consumption
Trying to postpone going to the bathroom
Reducing carbonated drinks
Practiced holding it
Reducing excessive fluid intake
Voiding at regular intervals
Decreasing fluids after a certain time of day
Frequent voids to keep the bladder empty
Limiting fluids if away from a restroom
Emptying the bladder at certain times
Wearing protective absorbent pads
Kegels (pelvic muscle exercises)
Sleeping on protective pads
Reducing caffeine intake
Attempted weight loss
Have you ever been given samples of or been prescribed any of the following? Check ALL boxes that apply.
Oxybutynin
Enablex®
Sanctura®
Detrol®
Gemtesa®
Toviaz®
Myrbetriq®
Vesicare®
Tibial Nerve Stimulation
Botox®
InterStim®
Other medication
The following conditions might affect your ability to take overactive bladder (OAB) medications. Check ALL boxes that apply
Chronic dry mouth
Glaucoma
History of constipation
History of fast heart rate (tachycardia)
Mild memory loss
History of heart failure (CHF)
Family history of dementia
Difficulty emptying the bladder
Elevated blood pressure
Taking more than 5 medications
History of hyperthyroidism
Cost of new, expensive medications
Age 65 and older (The American Geriatrics Society lists anticholinergics, including those commonly used to treat OAB, as a medication to be avoided in patients over the age of 65).
Risk of a fall (If you have fallen within the past year, are unsteady when standing or walking, or worried that you might fall, the Centers for Disease Control and Prevention (CDC) recommends eliminating anticholinergics, including those used to treat OAB).
Johns Hopkins recommends that patients having 3 or more of the following problems should avoid certain OAB medications. Check ALL boxes that apply
Muscle weakness
Decreased physical activity
Easily fatigued/tired
Slow walking speed
Weight loss
Poor balance/unsteady
Do you ever have accidents involving your bowels or have difficulty staying clean?
Please Select
Yes
No
How often do you have an accident involving the bowels? (Times daily)
How many times per day?
How often do you have an accident involving the bowels? (Times a week)
How many times per week?
How often do you have an accident involving the bowels? (Times a month)
How many times per month?
How long have your bowels been a problem?
Please Select
Not a problem
Less than 6 months
Greater than 6 months
Greater than 1 year
Greater than 5 years
Greater than 10 years
Bowel problems can have a negative impact on your quality of life. Check ALL boxes that apply.
Must avoid certain activities
Is a source of shame
Prevents a good night’s sleep
Causes me emotional distress
Interferes with work
Affects my relationships
Fear of leaving home
Interferes with intimacy
Restricts my independence
Fear of an odor
Difficult to travel
Often carry extra clothing
Wear dark clothing to hide accidents
Produces worry and frustration
Bowel problems disrupt my daily activities, including:
Increasingly embarrassing
Going grocery shopping
Going out with family or friends
Exercising regularly
Attending church or family events
Spending quality time with grandkids
Have you ever tried any of the following? Check ALL boxes that apply:
Watching what you eat
Adding fiber or bulk to your diet
Taking antidiarrheals like Imodium
Duration of therapy
Neurological condition, analrectoral malformation, or IBS
Yes
No
How often does this occur?
Please Select
Never
Daily
Several Times Weekly
Several Times Monthly
Less Than Once Monthly
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International Prostatism Symptom Score (IPSS)
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you found you stopped and started again several times when you urinated?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you found it difficult to postpone urination?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had a weak urinary stream?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had to push or strain to begin urination?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often did you most typically get up to urinate from the time you went to bed at night until the time you got up the next morning?
Please Select
None
Less than 1 in 5
Less than half the time
About half the time
More than half the time
Almost always
Have you ever tried Flomax?
Please Select
Yes
No
Have you had any previous prostate procedures?
Please Select
Yes
No
Have you had a cystoscopy (internal inspection of the bladder)?
Please Select
Yes
No
Signature
Date
Submit
Should be Empty: