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BPH

Assessment of demographic and clinical profiling of Indian patients of benign prostatic hyperplasia (BPH study)

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Patient Information

Patient's Age (years) *

Height (in cm) *

Weight (in Kg) *

Medical History

Previous Diagnosis of BPH *

Yes No

Family History of BPH *

Yes No

Other Urological Conditions *

Yes No {{-- If yes --}}

Symptoms

	If present, mention severity as per IPSS score
Frequency	0 1 2 3 4 5
Urgency	0 1 2 3 4 5
Nocturia	0 1 2 3 4 5
Incomplete Emptying	0 1 2 3 4 5
Intermittency	0 1 2 3 4 5
Weak Stream	0 1 2 3 4 5
Straining	0 1 2 3 4 5
Total IPSS Score (baseline)
Total IPSS Score (post treatment)

Erectile Dysfunction *

Yes No

Co-morbid Conditions	Medications
Hypertension	Yes No {{-- Please Specify --}}
Ischemic Heart Disease	Yes No {{-- Please Specify --}}
Heart Failure	Yes No {{-- Please Specify --}}
Diabetes	Yes No {{-- Please Specify --}}
Obesity	Yes No {{-- Please Specify --}}
Other Comorbidities	Yes No {{-- as per change 06-05-24 removed --}} {{-- Please Specify --}}

Investigations

{{--

PVR

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Prostate specific antigen (ng/ml) baseline

Prostate specific antigen (ng/ml) post treatment

PVR (ML) baseline

PVR (ML) post treatment

{{--

Prostate baseline (ng/ml)

Prostate post (ng/ml)

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Treatment Plan

Pharmacological Treatment *

	Drug name	dose (mg)	frequency (per day)	Duration (weeks)
Monotherapy
Combination therapy

Other

	Drug name	dose (mg)	frequency (per day)	Duration (weeks)
Combination therapy

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Other Treatment Recommendations

Name *

Dosage(s) *

Duration *

Frequency *

--}}

Surgical Intervention *

Transurethral Resection of the Prostate (TURP) Laser Surgery Prostatectomy None

{{--

Lifestyle Modifications Recommended (such as Fluid Intake or dietary Changes) *

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