Prostate Cancer Patient Consultation Form printable pdf download

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: ________

Prostate Cancer Patient Consultation Form