1. Your details
Required information
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Name
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Address
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Email
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Date of Birth
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Age
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Phone No.
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2. Tumour and prostate biopsy information
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Have you had a digital rectal examination (DRE) ?
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PSA level
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Free to total PSA ratio % ( if done )
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Gleason Score
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How many biopsy samples were taken ?
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How many of these samples had cancer ?
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Please attach pathology report hereOr fax us on 02 8382 6978
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3. Prostate information
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Size of prostate in cc (as shown on MRI report)
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Urinary symptoms
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Prostatitis (burning, pelvic pain)
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Fear of incontinence
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4. Local information
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Previous pelvic or abdominal surgery
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Type of surgery
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Previous radiotherapy
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Which region of the body was treated ?
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Previous pelvic injury
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Previous hernia operations
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5. Patient information
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a) Sexual factors
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Quality of erections
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Current relationship status
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single
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Importance of sexual function
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Preparedness to use sexual aids
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b) Bowel factors
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Bowel symptons
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Fear of bowel problems
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c) General health
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Longevity in family
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Medications
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Weight (kgs)
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Height (cms)
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d) Family history
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Prostate cancer
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Breast cancer
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Bowel cancer
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6. Staging tests
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PSMA PET Scan
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CT Scan
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MRI
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Please attach MRI or any other imaging report here or fax us on 02 8382 6978
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