PROSTATE CANCER HISTORY

NAME: __________________________________________DATE (mm/dd/yyyy)____/____/_____

The following information is for your use in providing a history and/or select data to requesting individuals on the list, and with your consent, for statistical analysis. All information submitted will be retained in confidence by the list moderator and the designated list statistician only, and will be released to no one else without your specific knowledge or consent.

WHEN DIAGNOSED (mmyyyy: ___________ PSA AT DIAGNOSIS: _________

WHAT PROMPTED SUSPICION OF PC - DRE, PSA, BOTH? ________________________________

WAS THE PSA INCREASE SUDDEN OR GRADUAL? _______________________________________

BIOPSY RESULT - TOTAL SAMPLES: ______, NUMBER POSITIVE: _______

GLEASON SCORE(S) ____________________

CANCER SPREAD BEYOND PROSTATE - N ___, Y ___, WHERE? __________________________

PRIORITIZE YOUR TREATMENT GOALS (1-4): ___ CURE, ___ BLADDER/BOWEL CONTROL,

___ SEX, ___ OTHER - SPECIFY _________________________________________________

TREATMENTS CONSIDERED (MEDICAL AND NON-MEDICAL): ____________________________
________________________________________________________________________________

TREATMENT(S) CHOSEN:______________________________________________________________

TREATMENT START DATE (mm/dd/yyyy): ___/___/___ LOCATION: ______________________

RESULTS/PROGNOSIS_______________________________________________________________

PSA TESTS AFTER - 3 MO._____ 6 MO._____ 9 MO._____12 MO._____

18 MO._____24 MO._____36 MO. _____ 48 MO._____

PARTICIPATION IN LOCAL SUPPORT GROUP? (Y/N) ____ HELPFUL?_______________________

RECURRENCE? (Y/N) ________ WHEN? (mmyyyy) _________TYPE? _______________________

TREATMENT DATE(S) (mm/dd/yyyy)______________TYPE: ______________________________

SERVICE IN RVN? Y___ N___

COMMENTS, OBSERVATIONS, SUGGESTIONS?

ABOVE INFORMATION MAY BE RELEASED TO: LIST STATISTICIAN - YES _____ NO _____
LIST MEMBERS - YES _____ NO _____


SIGNED: ______________________________