Prostate Medication Review "*" indicates required fields Prostate medications include Tamsulosin, Alfuzocin and Finasteride. After submission of this form: – The practice will continue your medication as usual if you have indicated you are happy with things – Otherwise the practice will contact you in a few days time days time to arrange a review.Name* First Last Date of birth* DD slash MM slash YYYY Mobile number to get in touch*Usual GP* eg Dr Turnbull / Dr Brooks You have been asked to complete this form to let us know whether you think your medication is working. These medications usually improve urinary symptoms caused by an enlarged prostate but sometimes there is little improvement. We would like to know whether you would like to continue or stop the medication. Additional information to help with your prostate symptoms can be found here.INCOMPLETE EMPTYING. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?* Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always FREQUENCY. Over the past month, how often have you had to urinate again less than two hours after you finished urinating?* Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always INTERMITENCY. Over the past month, how often have you found you stopped and started again several times when you urinated?* Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always URGENCY. Over the last month, how difficult have you found it to postpone urination?* Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always WEAK STREAM. Over the past month, how often have you had a weak urinary stream?* Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always STRAINING. Over the past month, how often have you had to push or strain to begin urination?* Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always NOCTURIA. Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?* None Once Twice Three times Four times Five times! IPSS Score*This score can help guide us and yourself on the severity of your prostate symptoms over time. 0-7 : Mild Symptoms 8-19 : Moderate Symptoms 20-35 : Severe Symptoms How would you like to proceed with your medication?* I think the medication is working and I would like to CONTINUE I do not think the medication is working and I would like to STOP I have had intolerable side effects and I would like to STOP I would like to DISCUSS with a GP Comments Optional This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.Consent* I agree to the privacy policy.© 2022 Kristian TurnbullCAPTCHA OptionalName OptionalThis field is for validation purposes and should be left unchanged.
