Prostate Cancer Patient Consultation Form (Page 2 of 3) in pdf

Prostate Cancer Patient Consultation Form Page 2

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

Prostate Cancer Patient Consultation Form Page 2