National Prostate Awareness Association - Prostate Cancer Registry

This registry is designed to record patient-reported Quality of Life issues in patients with Prostate cancer. To help us get the most accurate information and to be of the most benefit to readers, it is important that you answer all questions honestly and completely. Remember, as with all medical records, information contained within this registry will remain strictly confidential.

Our registry is based on the University of Michigan, The Expanded Prostate Cancer Index Composite (EPIC) instrument. This instrument was designed to evaluate patient function and bother after prostate cancer treatment. Additional information can be found at:

https://medicine.umich.edu/dept/urology/research/epic

Thanks for your participation,

Dr. James B. Hall,
National Executive Chairman, National Prostate Awareness Association

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    URINARY FUNCTION

    This section is about your urinary habits. Please consider ONLY THE LAST 4 WEEKS.
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    a. Dripping or leaking urine .........
    b. Pain or burning on urination.....
    c. Bleeding with urination.............
    d. Weak urine stream or incomplete emptying....................
    e. Waking up to urinate..............
    f. Need to urinate frequently during the day......
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    BOWEL HABITS

    This section is about your bowel habits and abdominal pain. Please consider ONLY THE LAST 4 WEEKS.
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    a. Urgency to have a bowel movement.......
    b. Increased frequency of bowel movements.....
    c. Watery bowel movements.............
    d. Losing control of your stools........
    e. Bloody stools......
    f. Abdominal/ Pelvic...........
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    SEXUAL FUNCTION

    The next section is about your current sexual function and sexual satisfaction. Many of the questions are very personal, but they will help us understand the important issues that you face every day. Remember, THIS SURVEY INFORMATION IS COMPLETELY CONFIDENTIAL. Please answer honestly about THE LAST 4 WEEKS ONLY.
    a. Your level of sexual desire?.......
    b. Your ability to have an erection?....
    c. Your ability to reach orgasm (climax)?.............
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    a. Your level of sexual desire.......
    b. Your ability to have an erection...
    c. Your ability to reach an orgasm..
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    HORMONAL FUNCTION

    The next section is about your hormonal function. Please consider ONLY THE LAST 4 WEEKS.
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    a. Hot flashes..........
    b. Breast tenderness/enlargement.....
    c. Loss of Body Hair........
    d. Feeling depressed........
    e. Lack of energy...........
    f. Change in body weight .
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    OVERALL SATISFACTION

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    THANK YOU VERY MUCH!!

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