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    PERSONAL INFORMATION

    CASE HISTORY

    Sr. Signs & Symptoms YES (Y) / NO(N) Duration
    1 Frequency of urination
    2 Urgency
    3 Nocturia (Frequency during the night)
    4 Incontinence (Leakage of urine)(Urge / Stress / Nocturnal)
    5 Pelvic pain
    6 Incomplete emptying of the bladder
    7 Episodes of near retention
    8 Voiding small volume of urine
    9 Spraying / Double streaming
    10 Haematuria (Blood in urine)
    11 Burning & Dysuria
    12 Straining
    13 Hesitancy (Difficulty in starting flow)
    14 Poor flow of urine
    15 Dribbling of urine
    16 Intermittency (Interrupted flow)
    17 Haemospermia (Blood in the semen)
    18 Retrograde ejaculation (semen doesn’t express during sexual activity)
    19 Reduced ejaculation force
    20 Discharge from the urethra
    21 Pain in the Scrotum / Testicles
    22 Dyspareunia (Painful sexual activity)
    23 Fever with chills & rigors

    OTHER INFORMATION

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