Prostate Artery Embolization (PAE) & AUA Symptoms - Request for Information

Thank you for your interest in Inova's Prostate Artery Embolization (PAE) program. Please fill out and submit this form to ask a question or receive more information.  You may also give us a call at Inova Alexandria Hospital (703-504-7950) or Inova Mount Vernon Hospital (703-664-7462) or visit our website. You must have JavaScript enabled to use this form. Thank you for contacting Inova about prostate artery embolization (PAE). Please click on the button near the response that most closely corresponds to your symptoms. Once you have completed all of the questions, add up the points corresponding to each of your answers and put the total number in the box at the bottom of the form. When finished, press the blue "Submit" button to send your form. You will hear back shortly about your test results. Thank you for completing this form. First Name Last Name Email Phone Address Address Address 2 City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code 1. PAE is offered at two Inova hospitals. Please indicate at which hospital you wish to receive service. PAE Hospitals Inova Alexandria Hospital Inova Mount Vernon Hospital 2. INCOMPLETE EMPTYING Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Incomplete Emptying Select List - Select -0 points -- Not at all1 point -- Less than 1 time in 52 points -- Less than half the time3 points -- About half the time4 points -- More than half the time5 points -- Almost always 3. FREQUENCY Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? Frequency Select List - Select -0 points -- Not at all1 point -- Less than 1 time in 52 points -- Less than half the time3 points -- About half the time4 points -- More than half the time5 points -- Almost always 4. INTERMITTENCY Over the past month, how often have you found that you stopped and started again several times when you urinated? Intermittency Select List - Select -0 points -- Not at all1 point -- Less than 1 time in 52 points -- Less than half the time3 points -- About half the time4 points -- More than half the time5 points -- Almost always 5. URGENCY Over the past month, how often have you found it difficult to postpone urination? Urgency Select List - Select -0 points -- Not at all1 point -- Less than 1 time in 52 points -- Less than half the time3 points -- About half the time4 points -- More than half the time5 points -- Almost always 7. STRAINING Over the past month, how often have you had to push or strain to begin urination? Straining Select List - Select -0 points -- Not at all1 point -- Less than 1 time in 52 points -- Less than half the time3 points -- About half the time4 points -- More than half the time5 points -- Almost always 8. NOCTURIA Over the past month or so, how many times did you get up to urinate from the time you went to bed until the time you got up in the morning? Nocturia Select List - Select -0 points -- None1 point -- 1 time2 points -- 2 times3 points -- 3 times4 points -- 4 times5 points -- 5 or more times 9. YOUR TOTAL AUA SCORE Add up the points for each answer you gave above and place the total number of points in the box. Total Aua Score 10. ONE LAST QUESTION If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Last Question Select List - Select -DelightedPleasedMostly satisfiedMixedMostly dissatisfiedUnhappyTerrible Please enter any further questions or comments here. By submitting this form, you are confirming that you would like to receive health and wellness information from Inova. You can unsubscribe if you find it is not meeting your needs. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.