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Date:
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Name:
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Age:
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Prostatitis History:
How long have you had it? What do you think caused it? Which are the worst symptoms? Which treatments have you had? How is prostatitis affecting you?
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| Pain or Discomfort |
Please select the single best answer: |
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1. In the last week, have you experienced any pain or discomfort in the following areas?:
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a. Area between rectum and testicles (perineum):
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b. Testicles:
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c. Tip of the penis (not related to urination):
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d. Below your waist, in your pubic or bladder area:
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2. In the last week, have you experienced:
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a. Pain or burning during urination?:
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2b. Pain or discomfort during or after sexual climax (ejaculation)?:
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| 3. How often have you had pain or discomfort in any of these areas over the last week? |
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| 4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week? |
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| Urination: |
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| 5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?: |
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| 6. How often have you had to urinate again less than two hours after you finished urinating, over the last week? |
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| Impact of Symptoms |
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| 7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week? |
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| 8. How much did you think about your symptoms, over the last week? |
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| Quality of Life |
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| 9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that? |
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Score:
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Please add the numbers on the left side of answers. |
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Other illnesses:
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Previous surgery:
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Medications, doses:
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Smoking history:
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Height:
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Weight:
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Allergies:
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Telephones:
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email:
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Re-enter email:
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Address:
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Insurance:
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Comments:
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Other material:
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By fax (305 936 0498) or email please send us any other related material, such as medical records and insurance cards. If not difficult, please include a photograph. |
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Security Code: *
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