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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