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Marital Status
• • •
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Medications:
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Name of drug, strength, and frequency
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Exercise Level
• • •
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Are you dieting?
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# of meals you eat in a day?
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If yes, are you on a physician prescribed diet?
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Rank salt intake
• • •
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Rank fat intake
• • •
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Caffeine
• • •
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# of cups/cans per day?
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Do you drink alcohol?
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How many drinks per week?
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Do you currently use recreational drugs?
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Are you sexually active?
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Have you had/ have issues achieving or maintaining an erection?
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Date of last prostate/rectal exam?
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Any discomfort with intercourse?
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Any testicular pain or swelling?
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Do you usually get up to urinate during the night?
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Do you feel pain or burning with urination?
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Any blood in your urine?
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Has the force of your urination decreased?
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Kidney, bladder, or prostate infections in the last year?
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Do you have any problems emptying your bladder completely?
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Mental Health
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Is stress a major problem for you?
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Do you feel depressed?
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Do you have trouble sleeping?
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