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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:
____________________________________________________________
____________________________________________________________
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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:
2nd opininon options:
- Urological oncologist ______________________________
- Radiation oncologist ______________________________
- Medical (genito-urinary) oncologist ___________________
- Alternative/Complementary Medicine specialist ________
Notes:___________________________________________________
________________________________________________________
________________________________________________________
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