Genitourinary History	Yes / No
Number of times that you urinate at night?	0-1
Number of times that you urinate during the day?	5
Any trouble starting the urine stream?	N
Any trouble stopping the urine stream?	N
Any pain with urination?	N
Any difficulty holding urine?	N
Any back pain related to urination?	N
Ever had blood in urine?	N
Ever had puffiness of face or eyes?	N

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