Clone of Southern Delaware Vascular Insitute GAE Questionnaire

1

Have you been diagnosed with an enlarged prostate (BPH)?* This field is required.

YESNO

2

By age 60, more than half of men

experience prostate enlargement

3

Are you experiencing any of the following symptoms?* This field is required.

Frequent urination, especially at night

Weak or interrupted stream

Difficulty starting urination

Urgency or leakage

Feeling bladder isn’t empty

None

4

Have these symptoms impacted your quality of life?

YESNO

5

Have you already tried treatments like medications or minimally invasive procedures (UroLift, Rezūm, TURP)? * This field is required.

YESNO

6

PAE can help when other treatments have not worked, or can be considered as a first-line option.

7

When was the last time you saw a urologist or primary care doctor for prostate symptoms?

Within The Last Year

1 - 3 Years

More Than 3 Years

Never

8

It's important to see a urologist to confirm diagnosis and rule out prostate cancer before treatment.

9

Would you like a consultation with one of our specialists to learn more about PAE?

YESNO

10

Name* This field is required.

First Name

Last Name

11

Email* This field is required.

example@example.com

12

Please provide the best number for our medical assistant to contact you?* This field is required.They will give you a call to discuss your options.

13

What is your preferred contact method?* This field is required.

14

We're on it!

Look out for a call from our medical assistant, who will schedule your visit.

By the way, your medical assistant is a real person who will answer any questions that you may have.

You may be asked to provide and/or confirm the information that you submitted to schedule your consultation.

We can't wait to talk to you!

15

Traditional surgical options may be more appropriate

16

You may not be a candidate for PAE

at this time.

17

Thank you for taking our quiz!

When you are ready to learn more about our ground breaking treatments for PAE, you can contact us at (302) 779 - 8440

Southern Delware Vascular Institute

https://www.sdevi.org

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