Mhf v3 mono

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FOR THE PAST MONTH
Date of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MALE HEALTH INVENTORY
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current PSA level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . These questions are designed to help you and your doctor identify 5. Over the past month, during sexual intercourse, how often were you
whether you may be experiencing erectile dysfunction, also known as
able to maintain your erection after you had penetrated (entered) impotence. If you are, and your treatment worsens the condition, you
may wish to discuss the treatment options with your doctor.
Did not Almost never A few times Sometimes Most times Circle the response that best describes your own situation. Please
be sure that you select one and only one response for each question.
1. Could you get an erection sufficient for intercourse? 2. Are you currently taking Viagra, Levitra or Cialis? 6. Over the past month, during sexual intercourse, how difficult was it
to maintain your erection to completion of intercourse? 3. Over the past month, how do you rate your confidence that 4. Over the past month, when you had erections with sexual 7. Over the past month, when you attempted sexual intercourse, how
stimulation, how often were your erections hard enough for
often was it satisfactory for you?
Did not Almost never A few times Sometimes Most times Almost never A few times Sometimes Most times These questions relate to your current ease of urination and are of
6. Straining Over the past month, how often have you had to push or
great importance in assessing you for Brachytherapy and for your
follow-up. Please circle the closest answer to how you have felt over the last Not at all Less than Less than About half More than 1. Incomplete Emptying Over the past month, how often have you
had a sensation of not emptying your bladder completely after youfinish urinating? 7. Nocturia Over the past month, how many times on average did
Not at all Less than Less than About half More than 2. Frequency Over the past month, how often have you had to urinate
again less than 2 hours after you finished urinating? Quality of Life due to Urinary Symptoms If you were to spend the rest
Not at all Less than Less than About half More than of your life with your urinary condition just the way it is now, how would
you feel about that?
3. Intermittency Over the past month, how often have you found you
had stopped and started again several times when you urinated? Not at all Less than Less than About half More than These questions relate to your bowel function.
1. Have your daily activities been limited by your bowel problems? 4. Urgency Over the past month, how often have you found it difficult
Not at all Less than Less than About half More than 2. Have you had any unintentional release (leakage) of stools? 5. Weak Stream Over the past month, how often have you had a weak
Not at all Less than Less than About half More than 4. Did you have a bloated feeling in your abdomen? Prostate Brachytherapy Centre, Guildford Thank you for completing this questionnaire

Source: http://www.prostatespecialist.co.uk/files/other/Patient_Information_Form_fax.pdf