Prostate
Health
Assessment
Takes less than
5 minutes
Generates
personalized report
Uses
IPSS
(Internationally recognized urinary symptom scores)
Dynamic
Risk Assessment
Shareable with your
doctor
Additional
FREE resources
, advice and support available
Let’s Get Started
Personal
Information
Name:
Weight (LBS):
Height (please enter in both foot and inches):
Foot:
Inches:
Date Of Birth:
Next
My Prostate
symptoms
What is your PSA level? (Please Enter Numeric Value Only)
I do not know
Approximately when was your last PSA test?(yyyy-mm-dd)
I do not know
Have you had a prostate biopsy?
No
Yes
Did it detect Prostate Cancer?
-- Select --
The diagnosis came back as positive for prostate cancer
The diagnosis came back as negative for prostate cancer
What is your Gleason score?
--
Have you had treatment for Prostate Cancer?
-- Select --
I previously have had treatment
I am currently being treated
I have not had any specific treatment for prostate cancer
Do you take any medication for your prostate health?
No
Yes
Which medication do you take?
-- Select --
Flomax/ Tamsulosin
Rapaflo/ Silodosin
Avodart/ Dutasteride
Proscar/ Finasteride
Uroxatral /Alfuzosin
Terazosin /Hytrin
Prazosin /Minipress
Doxazosin /Cardura
Other
Over the past month, how often have you had to stop and start again several times while urinating?
-- Select --
not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you experienced a weak urinary stream?
-- Select --
not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you felt like you have not emptied your bladder?
-- Select --
not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how regularly have you had to strain to start urinating?
-- Select --
not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
During an average 24 hour day/night cycle, how often do you feel the need to urinate?
-- Select --
Up to 7
8-9
10-11
12-13
13-14
15+
Over the past month, how frequently have you experienced a strong and sudden urge to urinate?
-- Select --
not at all
Less than 1 in 5 times
Less than half the time
About half the time
More than half the time
Almost always
How regularly do you experience erectile dysfunction/ sexual dysfunction?
-- Select --
I never experience erectile or sexual dysfunction
I rarely experience erectile or sexual dysfunction
I experience occasionally experience erectile or sexual dysfunction
In approximately half of all sexual situations I experience erectile or sexual dysfunction
I normally experience some erectile or sexual dysfunction on a regular basis
I always experience erectile or sexual dysfunction
What is your primary prostate health concern?
--Select--
BPH
Prostate Cancer
Prostatitis
Do you have any other prostate health concerns? [Pick up to 5]
High PSA
Urinary Urgency
Groin Pain
Erectile Dysfunction
Sexual Dysfunction
Weak Urinary Stream
Frequent Urination
Difficulty Emptying Bladder
Waking up at Night
Urinary Tract Infections
Incontinence
Drug Side Effects
Catheterization
You Have Selected
Back
Get Result
My Results
Thanks for completeing our assessment, we will send the full document to an email address of your choice. If you have any further questions don’t hesitate to contact us on
Tel:+1-888-868-3554
Where should we send your results?
* By signing up you agree to our terms and
privacy policy
.
Send My Result
