Symptoms Check Questionnaire
Q1 About you...
Please answer the questions below by ticking the boxes that apply to you.
If you are not sure about any of the questions, leave them blank and the
pharmacist will help you.
Q1 About you...
Q1a
Are you under the age of 45 years?
Q1b
Are you over the age of 75 years?
Q1c
Have you had prostate surgery?
Q1d
Has your doctor ever diagnosed you as having diabetes?
If Yes to any of the above, consult your pharmacist before
proceeding further with the questionnaire
Q2 About your urinary symptoms…
Q2a
Has your doctor already diagnosed you as having an
enlarged prostate gland otherwise known as BPH (benign prostatic hyperplasia)?
Q2b
If you have answered Yes to Q2a are you currently
taking any prescribed medicines for your BPH from your GP?
Q2c
Have you had these urinary (peeing) symptoms for
at least 3 months?