Get Qualified

First name

Last name

Email

Phone

Age

Have you ever been diagnosed with Prostatic Disease?

Yes

No

Have you ever been diagnosed with Benign Prostatic Hyperplasia (BPH)?

Yes

No

Have you ever been diagnosed with cancer?

Yes

No

Have you ever been diagnosed with Prostatitis?

Yes

No

Have you ever been diagnosed with Prostatic Intraepithelial Neoplasia (PIN)?

Yes

No

Have you ever had an enlarged prostate?

Yes

No

Do you currently have symptoms of a Urinary Tract Infection (UTI)?

Yes

No

Are you currently being treated for the following?

In the past 12 months, have you experienced any of the following?

Increased frequency of urination (approximately every three hours)

Increased urgency (sudden urge to urinate)

Sensation of incomplete emptying after urination

Hesitancy (indicative of urinary retention)

Decrease in force of urinary stream

Painful urination

Blood in urine

None of the above