BPH / Aquablation
Enquiry Form

Use this form to securely share your urinary symptoms and interest in Aquablation therapy. Your responses help our clinical team determine the most appropriate next steps for your care

BPH / Aquablation Enquiry Form

BPH / Prostate Symptoms & Aquablation Enquiry

This form helps us understand your urinary symptoms and interest in treatment options, including Aquablation. It takes approximately 5–8 minutes to complete.

Submitting this form does not constitute a medical consultation. If further assessment is needed, any fees will be explained clearly before booking is confirmed.

About You

Personal details

First Name

Last Name

Date of Birth

Address Line 1

Mobile Number

Occupation

Address Line 2 (Optional)

GP Name & Practice (optional)

Symptom Score (IPSS)

7 scored questions + Quality of Life question — calculated score displayed

The International Prostate Symptom Score (IPSS) is a validated clinical tool used worldwide to assess urinary symptoms and guide treatment. Please answer each question based on the past month.

Over the past month, how many times do you usually get up at night to pass urine?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Over the past month, how often have you needed to pass urine again less than two hours after finishing?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Over the past month, how often have you found your urine stream stops and starts several times?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Over the past month, how often have you found it difficult to delay passing urine once you feel the urge?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Over the past month, how often have you had a weak urinary stream?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Over the past month, how often have you needed to push or strain to begin urination?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

Over the past month, how often have you needed to push or strain to begin urination?

Not at all

Less than 1 in 5 times

Less than half the time

About half the time

More than half the time

Almost always

If your urinary symptoms stayed exactly as they are now for the rest of your life, how would you feel?

Delighted

Pleased

Mostly satisfied

Mixed

Mostly dissatisfied

Unhappy

Terrible

Your Symptom Score.

Symptom checklist and retention history

Symptom checklist and retention history

Symptom checklist and retention history

Waking at night to pass urine (nocturia)

Sudden urgent need to pass urine

Leakage before reaching the toilet

Voiding (flow) symptoms — select all that apply

Slow urinary flow

Difficulty starting urination (hesitancy)

Stop-start urinary stream

Straining to pass urine

Feeling of incomplete bladder emptying

Have you had urinary retention?

No history of urinary retention

Previous episode(s) of retention that resolved

Currently catheterised due to retention

If you are currently using a catheter, we recommend contacting us directly to arrange an early appointment. Phone: 01642 699 066. WhatsApp: 07984 448 243.

Any other reason for contacting us?

Previous Prostate Assessment

PSA, scans, previous urology consultations

Have you previously been assessed for prostate symptoms?

Not sure

Yes

Please describe any previous prostate assessment

Prostate size (if known)

PSA blood test result (if known)

Was your PSA described as normal?

Not sure

Yes

I do not know my PSA result

Current & Previous Treatment

Medications, previous surgery, urethral/bladder history

Are you taking medication for prostate or bladder symptoms?

Not sure

Yes

Please list your prostate or bladder medications

Have you had previous prostate surgery?

Not sure

Yes

Please give details of previous prostate surgery

Have you had any of the following? (select all that apply)

Previous bladder surgery

Urethral dilation

Urethrotomy

Known urethral stricture

Previous cystoscopy

Recurrent urinary infections

Other urethral or bladder procedure

General Health

Medical conditions, blood-thinning medication, allergies

Please select any relevant medical conditions (select all that apply)

High blood pressure

Diabetes

Heart disease

Previous stroke or TIA

Kidney disease

Parkinson's disease

Multiple sclerosis

Breathing or lung disease

Sleep apnoea

Other neurological condition

Any other medical problems not listed above?

Are you taking blood-thinning medication?

Not sure

Yes

Please provide details of blood-thinning medication

Do you have any known allergies?

Yes

Please list your allergies

Treatment Awareness & Preferences

Aquablation interest, treatment knowledge, desired next step

Are you specifically interested in Aquablation?

No — I am open to discussing all options

Not sure — I would like guidance on which treatment is right for me

Yes — I have researched Aquablation and want to know more

Aquablation is a modern robotic treatment that removes prostate tissue using a high-pressure waterjet — without heat. NICE approved. 96% patient satisfaction (WATER II trial). Lower risk of sexual side effects vs TURP. Suitable for a wider range of prostate sizes. Performed at Ramsay Tees Valley Hospital, Middlesbrough.

Which treatments have you heard about or considered? (select all that apply)

TURP (transurethral resection of the prostate)

HoLEP (holmium laser enucleation)

Aquablation (robotic waterjet treatment)

UroLift (prostatic urethral lift)

Rezūm (water vapour therapy)

Medication only

I have not considered any specific treatment yet

What would you like to do next?

I would like a consultation to discuss my symptoms / I am interested specifically in Aquablation and would like a consultation / I would like general advice before deciding on next steps

I am just exploring options at this stage

Consent & Submission

Declaration and final submit

If you choose to proceed: A formal consultation will be arranged. Further tests may be required (e.g. urine flow rate test, ultrasound scan, cystoscopy). Any chargeable assessments will be explained clearly before booking is confirmed. You will receive a personalised treatment recommendation based on your findings.

I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this form does not replace a medical consultation and that further specialist assessment may be chargeable.

BPH / AquablationEnquiry Form

BPH / Prostate Symptoms & Aquablation Enquiry

About You

Symptom Score (IPSS)

Symptom checklist and retention history

Previous Prostate Assessment

Current & Previous Treatment

General Health

Treatment Awareness & Preferences

Consent & Submission

BPH / Aquablation
Enquiry Form