PROSTATE CANCER HISTORY FORM

NAME: __________________________________________ TODAY’S DATE (mm/dd/yy) ____/____/_____  

The following information is for you use in recording your PC history.  If you chose, the form may be used  by you in providing your history easily and simply to those you wish to have it. If you chose to provide a copy to the List Moderator, all information will be retained in confidence by him and the Alternate Moderator only. Your history will be not released to anyone without your specific knowledge or consent.  Data from History Forms may be used for statistical analysis in an anonymous format.

 WHEN DIAGNOSED (mm/yyyy):  ___________                                    PSA AT DIAGNOSIS: _________

 WHAT PROMPTED SUSPICION OF PC – DRE, PSA, BOTH?  _________________________________

 WAS THE PSA INCREASE SUDDEN OR GRADUAL? _______________________________________

 BIOPSY RESULT - TOTAL SAMPLES: ______, NUMBER POSITIVE: _______

 GLEASON SCORE(S) ____________________

 CANCER SPREAD BEYOND PROSTATE – N: ___,  Y: ___, WHERE? __________________________

 PRIORITIZE YOUR TREATMENT GOALS (1-4):  ___ CURE, ___ BLADDER/BOWEL CONTROL,

 ___ SEX,  ___ OTHER – SPECIFY ________________________________________________________

 TREATMENTS CONSIDERED (MEDICAL AND NON-MEDICAL): ____________________________                                                 

 ______________________________________________________________________________________

 TREATMENT(S) CHOSEN:______________________________________________________________

 TREATMENT START DATE (mm/dd/yy): ___/___/___  LOCATION: ____________________________

 RESULTS/PROGNOSIS__________________________________________________________________

 PSA TESTS AFTER - 3 MO._____ 6 MO._____    9 MO._____12 MO._____

                                   18 MO._____24 MO._____36 MO. _____ 48 MO._____

PARTICIPATION IN LOCAL SUPPORT GROUP? (Y/N) ____ HELPFUL?________________________

RECURRENCE? (Y/N) ________ WHEN? (mmyyyy) _________TYPE? __________________________

TREATMENT DATE(S) (mm/dd/yy)______________TYPE: ___________________________________

 COMMENTS, OBSERVATIONS, SUGGESTIONS?

ABOVE INFORMATION MAY BE RELEASED TO: LIST MEMBERS – YES _____ NO ____