Laparoscopic Prostate Removal
for Severe, Treatment-Resistant
Chronic Prostatitis

                                                                            

Tel: 305-504-8470
                          Send e-mail                      
Online Consultation

 

 

 

 

Consultation: Online, easy, and free of charge.

Please provide as much information as possible. We will get back to you quickly.
If you have any questions, please call us at 305-504-8470.

Date:

Name:

Age:

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?

Pain or Discomfort Please select the single best answer:

1. In the last week, have you experienced any pain or discomfort in the following areas?:

a. Area between rectum and testicles (perineum):

b. Testicles:

c. Tip of the penis (not related to urination):

d. Below your waist, in your pubic or bladder area:

2. In the last week, have you experienced:

a. Pain or burning during urination?:

2b. Pain or discomfort during or after sexual climax (ejaculation)?:

3. How often have you had pain or discomfort in any of these areas over the last week?
4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?
Urination:
5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?:
6. How often have you had to urinate again less than two hours after you finished urinating, over the last week?
Impact of Symptoms
7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?
8. How much did you think about your symptoms, over the last week?
Quality of Life
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?

Score:

Please add the numbers on the left side of answers.

Other illnesses:

Previous surgery:

Medications, doses:

Smoking history:

Height:

Weight:

Allergies:

Telephones:

email:

Re-enter email:

Address:

Insurance:

Comments:

Other material:

By 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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