Prostate Artery Embolization Treatment Questionnaire

Fill out the following questionnaire to see if you are a candidate for prostate artery embolization (PAE).

Step 1 of 2

Are you exploring an alternative treatment to surgery or another recommended procedure for your benign prostatic hyperplasia?(Required)

Yes

During the past month, have you experienced any of the following? (Check all that apply.)(Required)

Difficulty fully emptying your bladder

Frequent urination during the day (sometimes more than once within a 2-hour period)

Have to get out of bed to urinate at night

Weak urine stream

Have to push or strain to start urinating

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

How soon would you like to schedule a consultation?(Required)

As soon as possible

2-4 weeks

4+ weeks

Undecided