Thank you for your interest in Inova's Prostate Artery Embolization (PAE) program. Please fill out and submit this form to ask a question or receive more information. 

Please click on the button near the response that most closely corresponds to your symptoms. Once you have completed all of the questions, add up the points corresponding to each of your answers and put the total number in the box at the bottom of the form.

When finished, press the blue "Submit" button to send your form. You will hear back shortly about your test results. Thank you for completing this form.

You may also give us a call at Inova Alexandria Hospital (703-504-7950) or Inova Mount Vernon Hospital (703-664-7462) or visit our website.

1. PAE is offered at two Inova hospitals. Please indicate at which hospital you wish to receive service.

2. INCOMPLETE EMPTYING
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

3. FREQUENCY
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
4. INTERMITTENCY
Over the past month, how often have you found that you stopped and started again several times when you urinated?
5. URGENCY
Over the past month, how often have you found it difficult to postpone urination?
7. STRAINING
Over the past month, how often have you had to push or strain to begin urination?
8. NOCTURIA
Over the past month or so, how many times did you get up to urinate from the time you went to bed until the time you got up in the morning?
9. YOUR TOTAL AUA SCORE
Add up the points for each answer you gave above and place the total number of points in the box.
10. ONE LAST QUESTION
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

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