What is your ZIP/Postal Code?
Where did you learn about this research study?	--Select-- Facebook Instagram Radio Flyer/Brochure Doctor Word of Mouth Other
If other, please specify
Are you completing this form for yourself or someone else?	--Select-- Self Someone Else
Note: If completing for someone else, the "you" or "your" in the questions below refers to the potential participant.
Are you a male age 45 or older?	--Select-- Yes No
Are you currently taking any medication for benign prostatic hyperplasia also known as BPH or an enlarged prostate?	--Select-- Yes No
On average, how many times in a 24 hour period do you use the bathroom?	--Select-- 0-3 4-7 8-10 more than 10
On average, how many times do you wake up at night to use the bathroom?	--Select-- None 1 2 3 or more
Do you experience a need to use the bathroom immediately which is also called urinary urgency?	--Select-- Yes No
Do you typically work nightshift hours?	--Select-- Yes No
Have you been diagnosed with sleep apnea?	--Select-- Yes No
Are you taking herbal suppliments for your OAB, BPH, a urinary tract infection or erectile dysfunction?	--Select-- Yes No Unknown
Within the past 5 years, have you had cancer other than basal cell carcinoma of the skin?	--Select-- Yes No Unknown
Have you participated in another clinical trial in the past 30 days?	--Select-- Yes No
Please select a study doctor's office where you would want to attend study visits.	Find Study Location