Prostate Cancer Survivorship Questionnaire

Prostate Cancer Survivorship Questionnaire
Following prostate cancer treatment, some patients may have some prolonged sexual health concerns. Complete this questionnaire to assess your sexual health. If needed, treatments are available.
Name*

First NameLast Name
Date*

MonthDayYear
Birthday*

MonthDayYear
Phone Number*

Area CodePhone Number
How do you rate your confidence that you could get and keep an erection?*

1 - Very Low2 - Low3 - Moderate4 - High5 - Very High
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?*

1 - Almost never or none2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half the time)5 - Almost always or always
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*

1 - Almost never or none2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half the time)5 - Almost always or always
During sexual intercourse, how difficult is it to maintain your erection to completion of intercourse?*

1 - Extremely difficult2 - Very difficult3 - Difficult4 - Slightly difficult5 - Not difficult
When you attempted sexual intercourse, how often was it satisfactory for you?*

1 - Extremely difficult2 - Very difficult3 - Difficult4 - Slightly difficult5 - Not difficult
Total*
The Sexual Health Inventory for Men classifies erectile dysfunction severity with the following breakpoints:
- 1-7, Severe ED
- 8-11, Moderate ED
- 12-16, Mild-moderate ED
- 17-21, Mild ED
- 22-25, No ED
Check any ED treatments you have tried:*

Pills/MedicationVacuum deviceInjection therapyMUSEOther
Bladder Health Assessment

Answer the bladder health questions by checking the boxes and filling in your information.
How long ago did you complete your prostate cancer treatment?*
Years, Months
Do you experience urine leakage?*

YesNo
Which symptoms best describe you? (Check all that apply)*

Leakage with little or no warning(sometimes unable to make it to the bathroom in time)Frequent urination (day, night, or both)Accidental leakage with physicalactivity (e.g., exercising)Other
Do you wear pads or diapers, use a urine collection device or a penile clamp? (Check all that apply)*

PadsDiapersUrine collection devicePenile Clamp
How many pads do you wear per day?*
How many diapers do you wear per day?*

If you are interested in discussing your assessment results and learning about durable treatment options, call (229) 883-1503 to make an appointment with one of our doctors. Please print and bring your assessment to your appointment.
Should be Empty:

Prostate Cancer Survivorship Questionnaire

Bladder Health Assessment