Prostate MRI Questionnaire
U3T
Patient Name:
Date of Birth:
Age:
AHC #:    
Patient Height: in/cm   Patient Weight lbs/kgs

Is there a history of a prostate biopsy? No Yes

If yes, please provide dates and results:

Dates and results for ALL PSAs done:

Date: Result:

Date: Result:

Date: Result:

Is there a history of treatement for prostate disease in the past or currently receiving treatment?

No Yes

If yes, please describe:

Is there a history of any other pelvic disease? No Yes

If yes, please describe:

Is there a history of any pelvic surgeries / treatments? No Yes

If yes, please describe:


Questionnaire completed by:

Name (please print):

Signature:



 

 

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