Prostate Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *PhoneWhen you want to pass urine, is there a delay before you start? Never SometimesUsually When you pass urine, do you find your flow stops and starts? Never SometimesUsually When you think you have finished passing urine, do you find a bit more trickles out, and sometimes stains your underwear?Never SometimesUsually Has your stream become weaker or thinner in the past year?Not reallyYes, a bitYes, a lotDo you feel your bladder is not quite empty after you have been to pass urine? Never SometimesUsually How many times do you usually get up in the night to pass urine?Never 1 - 3 4 or more How many times do you go to pass urine in the daytime?Less than 4 5 - 7 More than 7 Do you ever pass urine when you don't mean to? Never SometimesOftenDo you ever leaked urine and felt embarrassed? Never SometimesOften Do you ever get hardness of organ in the morning without the urge of sex?Never SometimesMost of the time Have you noticed decline in your sex drive in the past? All of sudden Slowly diminishingNo change Do you feel lack of interest in sex from the past few years? No change Yes sometimesAlways felt like since few years Do you ever get your PSA test in past years? YesNoIf yes (number was ….)PhoneSubmit