1. Your details

Required information
Name
Address
Email
Date of Birth
Age
Phone No.

2. Tumour and prostate biopsy information

Have you had a digital rectal examination (DRE) ?  
PSA level
Free to total PSA ratio % ( if done )
Gleason Score
How many biopsy samples were taken ?
How many of these samples had cancer ?
Please attach pathology report here
Or fax us on 02 8382 6978

3. Prostate information

Size of prostate (grams or cc)
Urinary symptoms
Prostatitis (burning, pelvic pain)
Fear of incontinence *

4. Local information

Previous pelvic or abdominal surgery
Previous radiotherapy
Previous pelvic injury
Previous hernia operations

5. Patient information

a) Sexual factors

Quality of erections    
Current relationship status single
Importance of sexual function *
Preparedness to use sexual aids

b) Bowel factors

Bowel symptons  
Fear of bowel problems    

c) General health

Longevity in family
Medications
Weight (kgs)
Height (cms)

d) Family history

Prostate cancer
Breast cancer
Bowel cancer

6. Staging tests

PSMA PET Scan  
CT Scan  
MRI  
I have read the privacy policy and understand that by completing and sending this form I give St Vincents Prostate Cancer Clinic my consent for the collection and appropriate use of this information.
*