SYMPTOMS CHECK QUESTIONNAIRE

Take this questionnaire to better understand the severity of your urinary symptoms and whether Flomax Relief is suitable for you.

You will be asked a series of questions which may take you approximately 5–10 minutes to answer. Afterwards you will be given a personalised report which you can print and take to your Pharmacist or GP.

ABOUT YOU

Are you under the age of 45?

Are you over the age of 75?

Have you had prostate surgery?

Has your doctor ever diagnosed you as having diabetes?

ABOUT YOUR URINARY SYMPTOMS

Has your doctor already diagnosed you as having an enlarged prostate gland otherwise known as BPH (benign prostatic hyperplasia)?

Have you had these urinary (peeing) symptoms for at least 3 months?

SYMPTOMS

Do you experience any of the following symptoms?

Incomplete emptying

Over the past month, how often have you had the sensation of not emptying your bladder completely after you finish urinating (peeing)?

SYMPTOMS

Do you experience any of the following symptoms?

Frequency

Over the past month, how often have you had to urinate (pee) again less than 2 hours after you last urinated (peed)?

SYMPTOMS

Do you experience any of the following symptoms?

Intermittency

Over the past month, how often have you found you stopped and started again several times when you urinated (peed)?

SYMPTOMS

Do you experience any of the following symptoms?

Urgency

Over the past month, how difficult have you found it to postpone urination (peeing)?

SYMPTOMS

Do you experience any of the following symptoms?

Weak stream

Over the past month, how often have you had a weak urinary (pee) stream?

SYMPTOMS

Do you experience any of the following symptoms?

Straining

Over the past month, how often have you had to push or strain to begin urination (peeing)?

SYMPTOMS

Do you experience any of the following symptoms?

Nocturia

Over the past month, how many times did you most typically get up to urinate (pee) from the time you went to bed until the time you got up in the morning?

QUALITY OF LIFE

Do you experience any of the following symptoms?

If you were to spend the rest of your life with your urinary (peeing) condition the way it is now, how would you feel about that?

OTHER SYMPTOMS

Do any of these statements apply to you?

I am currently experiencing pain on urination (peeing)

I have had blood in my urine (pee) in the last 3 months

I have had cloudy urine (pee) in the last 3 months

I have got a fever at the moment

I have got leaking of urine (incontinence)

ABOUT YOUR MEDICAL HISTORY

At the moment, do you have:

Any problem with your liver?

Any problem with your kidneys?

Any problem with your heart?

Any fainting, dizziness or weakness when you stand up?

Any eye operation planned?

Any blurred or cloudy vision that has not been examined by your GP or Optician?

MEDICINES

Have you ever had an allergy to tamsulosin or a bad reaction to it?

Are you taking any other antihypertensive medicines or herbal supplements?
Example of these medicines are: Doxazosin, Indoramin, Prazosin, Terazosin, Verapamil.