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By submitting this form you are granting Medtronic permission to add your contact information to its database for Prostiva® RF Therapy and consent to receiving information and communications related to Medtronic products and therapies. You may revoke this permission at any time by e-mailing prostiva@medtronic.com or sending a request in writing to: Medtronic Prostiva RF Therapy, 7000 Central Avenue NE, RCE 240, Minneapolis, MN 55432-3576.

1. How did you hear about Prostiva RF Therapy? Doctor
   Seminar/Event
   Media (newspaper, TV, advertisement)
   Other
2. Who is this information for? Yourself
   Friend/Family Member
   I am a current Prostiva Patient
   
   Please answer the following questions so we can better understand how to help patients experiencing symptoms of BPH.
3. What is your age?
4. Have you been diagnosed with symptomatic enlarged prostate, also known as BPH? Yes
   No
5. If you have been diagnosed, what type of medical doctor provides primary treatment for your condition? Urologist
   Primary Care Physician
   Other
6. Are you experiencing any side effects from medications to treat your symptoms of an enlarged prostate (BPH) condition? Yes
   No
   Not Sure
   I’m not currently taking medications for enlarge prostate (BPH)
7. How would you feel if you had to live with your urinary condition the way it is now – no better, no worse – for the rest of your life?
   Based on a scale from 0 to 6 points (delighted to terrible), select the number below that best describes your feelings.
   
   0 - Delighted
   1 - Pleased
   2 - Mostly satisfied
   3 - Mixed
   4 - Mostly dissatisfied
   5 - Unhappy
   6 - Terrible
   
   Quality of Life (Bother) Score. Copyright 2003 American Urological Association Education and Research, Inc.^®
8. Do you know your Symptom Score? Yes, my symptom score is
   No

If not, the American Urological Association (AUA) developed a Symptom Score Index to help assess the severity of your BPH symptoms. This diagnostic¹ system includes seven questions to help measure how severe your BPH may be — ranging from mild to severe. Learn more

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