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Tel: 1.201.289.8221
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Prostate Cancer Patient Consultation Form

Name: _______________________________________________________

Address: _____________________________________________________

_____________________________________________________________

DETECTION: 

Symptoms:___________________________________________________

____________________________________________________________

____________________________________________________________

Initial PSA: ___________ Normal Range: ___________ Most Recent PSA: ___________ Free vs. Bound PSA: __________

EVALUATION: 

Yes: _______ No: ________ Positive DRE? 

Yes: _______ No: ________ Endo-rectal MRI? 

Yes: _______ No: ________ CT pelvis/abdomen? 

Yes: _______ No: ________ Bone scan? 

Yes: _______ No: ________ Chest X-ray? 

Prostascint Imaging? Positive:________ Negative:___________

RT-PCR Blood Assay? Positive: ________ Negative: _________ 

PAP (prostatic acid phosphatase) results: ________________ Normal range: ___________ 

Serum chemistries results:
BUN Creatine: __________/__________
Alkaline phosphatase: _______________________(nl to _______)
LDH ____________ (nl to _________)
Hematocrit _______________
Platelet count ______________

Needle biopsy performed? Yes: _______ No: ________
Number of cores: ________
Pathology comments:
____________________________________________________________

____________________________________________________________

____________________________________________________________

DIAGNOSIS: 

Yes: _______ No: ________ Prostate Cancer? 

Yes: _______ No: ________ Right Lobe involved? 

Yes: _______ No: ________ More than 1/2 of lobe? 

Yes: _______ No: ________ Left Lobe involved? 

Yes: _______ No: ________ More than 1/2 of lobe? 

Tumor size:____________

Yes: _______ No: ________ Seminal Vesicle involved? 

DNA Ploidy Analysis: Diploid ________ Aneuploid ________ Tetraploid __________

Gleason Grade: ______ + _______ = ________ 

Stage: ___________ 

Partin Table Score: _____________ 


TREATMENT: 

Detail any previous treatments for prostate cancer or any other urological condition: 
____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

What are the options available to me: 
_______ Radical Prostatectomy 
_______ Laparoscopic Radical Prostatectomy
_______ Cryo-Surgery
_______ Conformal Beam Radiation 
_______ Radiation Seed Implants (brachytherapy)
_______ Hormonal Therapy 
_______ Combination Hormonal Blockade 
_______ Intermittent Hormonal Therapy
_______ Chemotherapy
_______ Combination Chemotherapeutic Protocol
_______ Clinical Trial
_______ Active Surveillance (monitored by physician)
_______ Other ___________________________________________

Do you recommend hormonal therapy prior to, or after, the treatment selected? Yes: _____ No: _____
Why? ____________________________________________

What are the side-effects to the recommended treatment:? incontinence:______________________________________

sexual dysfunction: __________________________________

other: ____________________________________________

How many of these procedures have you done? ________ How frequently now? ___________

What is the prognosis for:

    survival ________________________________________________

    recurrence _____________________________________________

2nd opininon options:

- Urological oncologist ______________________________
- Radiation oncologist ______________________________
- Medical (genito-urinary) oncologist ___________________
- Alternative/Complementary Medicine specialist ________


Notes:___________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

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