* Name
Address
* Email
Date of Birth
* Phone Number
You may not know some or all of these.
PSA level
Free to Total PSA Ratio
Gleason Score - if known
Percentage of Biopsies Involved
Size of Prostate(grams)
Urinary Symptoms YES NO
Obstruction (hesitancy, poor flow and post-void dribbling) YES NO
Irritation (frequency, urgency and urge incontince) YES NO
Prostatitis (burning, pelvic pain) YES NO
Previous Pelvic or Abdominal Surgery - including previous prostate biopsies
Previous Radiotherapy - please include what region of body
Previous Pelvic Injury
Previous Hernia Operations
Obesity Overweight Slightly Overweight
A. Sexual
Quality of Erections Good Average Below Average
Current Relationship In Relationship Single
Importance of Sexual Function Very Important Important Somewhat Important
B. Urinary Status
Urinary Symptoms Continent of Urine Some Dribbling Post Urination Incontinent of Urine at Times
Fear of Incontinence High Medium Low
C. Bowel Status
Previous Bowel Treatments for Disease YES NO
Bowel Symptoms YES NO
Fear of Bowel Problems High Medium Low
D. General Healths
Age
Life Expectancy
Other Health Problems
Medications
E. Other Factors
Geographical Location - Where do you live?
Family History- any family history of prostate, bowel or breast cancer
Bone Scan
CT Scan
Chest X-ray
Other Tests (MRI, Ultrasound)
My team and I will ensure the highest standard of preoperative, operative and and post-operative care to ensure your treatment expectations are fairly met
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