General Information Patient Name: Patient DOB: Patient phone: Email: Health Care Providers (Including Names, Institution) Primary Care Provider: Urologic Surgeon: Radiation Oncologist: Medical Oncologist: Other Providers: Treatment Summary Diagnosis Cancer Type/Location/Histology Subtype: Prostate Cancer Diagnosis Date (year): ☐I ☐II ☐III ☐IV ☐Not Stage: applicable Gleason Score: PSA at Diagnosis: ☐ ☐No Clinical Trial: Yes Name/Number: Treatment Completed Surgery: Surgery Date(s) (year): Surgical procedure/location/findings: ☐ ☐No Prostate/Seminal Vesical only: End Date (year): External beam radiation: Yes ☐ ☐No Yes ☐ ☐No Whole pelvis: Yes End Date (year): ☐ ☐No End Date (year): Brachytherapy to prostate: Yes ☐ ☐No Systemic Therapy (chemotherapy, hormonal therapy, other): Yes Duration: Names of Agents Used End Dates (year) or ongoing ☐ Casodex ☐ Lupron (or similar LHRH agonist) ☐ Other Persistent symptoms or side effects at completion of treatment: □ No □ Yes (enter type(s)) : Treatment Ongoing ☐ ☐ Need for ongoing (adjuvant) treatment for cancer Yes No Additional treatment name Planned duration Possible Side effects Follow-up Care Plan Schedule of Clinical Visits Coordinating Provider When/How often Cancer Surveillance or other Recommended Tests Coordinating Provider Test How Often PSA (Prostate Specific Antigen)
General Information Patient Name: Patient DOB: Patient phone: Email: Health Care Providers (Including Names, Institution) Primary Care Provider: Urologic Surgeon: Radiation Oncologist: Medical Oncologist: Other Providers: Treatment Summary Diagnosis Cancer Type/Location/Histology Subtype: Prostate Cancer Diagnosis Date (year): Stage: ☐I ☐II ☐III ☐IV ☐Not applicable Gleason Score: PSA at Diagnosis: Clinical Trial: ☐ Yes ☐No Name/Number: Treatment Completed Surgery: Surgery Date(s) (year): Surgical procedure/location/findings: External beam radiation: ☐ Yes ☐No Prostate/Seminal Vesical only: ☐ Yes ☐No End Date (year): Whole pelvis: ☐ Yes ☐No End Date (year): Brachytherapy to prostate: ☐ Yes ☐No End Date (year): Systemic Therapy (chemotherapy, hormonal therapy, other): ☐ Yes ☐No Duration: Names of Agents Used End Dates (year) or ongoing ☐ Casodex ☐ Lupron (or similar LHRH agonist) ☐ Other Persistent symptoms or side effects at completion of treatment: □ No □ Yes (enter type(s)) : Treatment Ongoing Need for ongoing (adjuvant) treatment for cancer ☐ Yes ☐ No Additional treatment name Planned duration Possible Side effects Follow-up Care Plan Schedule of Clinical Visits Coordinating Provider When/How often Cancer Surveillance or other Recommended Tests Coordinating Provider Test How Often PSA (Prostate Specific Antigen)