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GENERAL CONTACT INFORMATION
* First Name:    * Last Name:   
* Email Address:    
Address: City:
State: Zip Code:
* Phone:    Fax:
How did you find the site:
PATIENT INFORMATION
Date of Birth:  (e.g., 05/02/1965)
Have you been diagnosed with prostate cancer:
If "Yes", please complete the following: 
When were you diagnosed:  (e.g., 05/02/2008)

Have you had previous treatment for prostate cancer?
(check all that apply):

 
 
 
 
 
* What was your PSA at the time of the diagnosis:
Current PSA & PSA History:
What was your highest Gleason score:
What was the date of your biopsy:  (e.g., 05/02/2008)
Size of Prostate (in grams):
Have you experienced recurrence:
Comments/Questions: