Second Opinion

1. Your details

Required information

Date of Birth
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 hereOr fax us on 02 8382 6978

3. Prostate information

Size of prostate in cc (as shown on MRI report)
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
Weight (kgs)
Height (cms)

d) Family history

Prostate cancer
Breast cancer
Bowel cancer

6. Staging tests

CT Scan
* 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.