Testing updated form

Facebook

Twitter

Social link

About you

First name *

Last name *

Date of birth *

What best describes your ethnicity? *

What best describes your gender? *

What best describes your sexuality? *

Is it you or your partner who has had a diagnosis of Prostate Cancer? *

Your journey with prostate cancer

Age at diagnosis *

Staging at diagnosis: *

Localised prostate cancer – contained inside the prostate

Locally advance prostate cancer – started to break out of the prostate or has spread to the area just outside it

Advanced prostate cancer – spread from the prostate to other parts of the body

What was your PSA level at diagnosis (Leave blank if unsure)

What was your Gleason score at diagnosis (Leave blank if unsure)

What diagnostic tests did you have? * Please select all that apply

MRI scan

Bone scan

CT scan

PSMA PET scan

DEXA scan

Trans-rectal ultrasound (TRUS) guided biopsy

Transperineal biopsy

Other

Diagnostic tests other Please specify

Were you diagnosed with the following before being diagnosed with prostate cancer? * Tick all that apply

Prostatitis

Enlarged Prostate

None of the above

Treatment (Primary treatment) * Your original treatment after diagnosis.

Active Surveillance

Brachytherapy High Dose Rate

Brachytherapy Low Dose

Chemotherapy

Cryotherapy

Hormone Therapy Combined with Other Treatment

Hormone Therapy Long Term (More than 6 months)

HIFU Primary Treatment

Olaparib

PSMA targeted treatment Lutetium-177

Radiotherapy Primary Treatment

Surgery Laparoscopic

Surgery Open

Surgery Robotic Laparoscopic

Watchful Waiting

If you had Hormone Therapy and know the name of the treatment you received, could you please specify here *

Date of primary treatment *

Treatment (Secondary treatment) * Any treatment given for recurrence or further spread after primary treatment.

Brachytherapy High Dose Rate

Brachytherapy Low Dose

Chemotherapy

Cryotherapy Salvage Treatment

Hormone Therapy Combined with Other Treatment

Hormone Therapy Long Term

HIFU Salvage Treatment

Radiotherapy Salvage Treatment

Radium 223

Surgery Laparoscopic

Surgery Open

Surgery Robotic Laparoscopic

Watchful Waiting

I did not receive secondary treatment

If you had surgery as a primary or secondary treatment, did you have a nerve sparing procedure? *

If you had Hormone Therapy as a secondary treatment and know the name of the treatment you received, could you please specify here

Date of secondary treatment *

Have you had any additional treatments aside from primary and secondary treatments? Please give details of the treatments and the dates you received them *

Side effects * Please tick all that apply

Bladder problems

Bowel problems

Breast side effects

Erectile Dysfunction - short term

Erectile Dysfunction - long term

Loss of libido

Side effects of Hormone Therapy

Urinary incontinence - Short term

Urinary incontinence - Long term

Pelvic Radiation Disease

Other

Side effects other Please specify

Did you receive any of the below treatments for side effects? * Please select all that apply

Pelvic floor exercises with physiotherapist support

Drug treatment for urinary incontinence such as alpha blockers or antimuscaranic

Artificial urinary sphincter

Sling

Drug treatment for erectile dysfunction such as PDE5I, MUSE or penile injections

Inflatable prosthesis or semi rigid prothesis

Vacuum pump

Treatment for hormone therapy side effects such as drugs for hot flushes, breast tenderness, treatment for depression or osteoporosis

Anti diarrhoea drugs for bowel issues

Other treatments relating to bowel or bladder side effects

No treatment for side effects

Other

Treatments for side effects other Please specify

Was the treatment you received for your side effects successful? *

What has been the impact of prostate cancer on your mental health and wellbeing? Please share details of any support you've received and things you did to help yourself *

What has been the impact of prostate cancer on your work and employment? Please share details of any support you've received and things you did to help yourself *

What has been the impact of prostate cancer on your relationships? Please share details of any support you've received and things you did to help yourself *

What has been the impact of prostate cancer on your sex life? Please share details of any support you've received and things you did to help yourself *

Did you make any diet and lifestyle changes after treatment? *

Yes

If yes, please describe

Do you have any interests or hobbies that you're happy to share with us *

Are there any other subjects about your lived experience of prostate cancer you would be uncomfortable to talk about with a service user? *

Are there any other details about your lived experience of prostate cancer that you would like to share? *

Your journey with prostate cancer

Your partner's age at diagnosis *

Your partner's staging at diagnosis: *

Localised prostate cancer – contained inside the prostate

Locally advance prostate cancer – started to break out of the prostate or has spread to the area just outside it

Advanced prostate cancer – spread from the prostate to other parts of the body

What was your partner's PSA level at diagnosis (Leave blank if unsure)

What was your partner's Gleason score at diagnosis (Leave blank if unsure)

What diagnostic tests did your partner have? Please select all that apply (if known)

MRI scan

Bone scan

CT scan

PSMA PET scan

DEXA scan

Trans-rectal ultrasound (TRUS) guided biopsy

Transperineal biopsy

Other

Diagnostic tests other Please specify

Was your partner diagnosed with the following before being diagnosed with prostate cancer? * Tick all that apply

Prostatitis

Enlarged Prostate

None of the above

What was your partners primary treatment? * Your partner's first treatment after diagnosis.

Active Surveillance

Brachytherapy High Dose Rate

Brachytherapy Low Dose

Chemotherapy

Cryotherapy

Hormone Therapy Combined with Other Treatment

Hormone Therapy Long Term (More than 6 months)

HIFU Primary Treatment

Olaparib

PSMA targeted treatment Lutetium-177

Radiotherapy Primary Treatment

Surgery Laparoscopic

Surgery Open

Surgery Robotic Laparoscopic

Watchful Waiting

If your partner had Hormone Therapy and you know the name of the treatment they received, please specify here

Date of partner's primary treatment *

Your partner's treatment (Secondary treatment) * Any treatment given for recurrence or further spread after primary treatment.

Brachytherapy High Dose Rate

Brachytherapy Low Dose

Chemotherapy

Cryotherapy Salvage Treatment

Hormone Therapy Combined with Other Treatment

Hormone Therapy Long Term

HIFU Salvage Treatment

Radiotherapy Salvage Treatment

Radium 223

Surgery Laparoscopic

Surgery Open

Surgery Robotic Laparoscopic

Watchful Waiting

I did not receive secondary treatment

If your partner had surgery as a primary or secondary treatment, did they have a nerve sparing procedure?

If your partner had Hormone Therapy as a secondary treatment and you know the name of the treatment they received, please specify here

Date of secondary treatment

Has your partner had any additional treatments aside from primary and secondary treatments? Please give details of the treatments and the dates received

What side effects did your partner experience? * Please tick all that apply

Bladder problems

Bowel problems

Breast side effects

Erectile Dysfunction - short term

Erectile Dysfunction - long term

Loss of libido

Side effects of Hormone Therapy

Urinary incontinence - Short term

Urinary incontinence - Long term

Pelvic Radiation Disease

Other

Side effects other Please specify

Did your partner receive any of the below treatments for side effects? * Please select all that apply

Pelvic floor exercises with physiotherapist support

Drug treatment for urinary incontinence such as alpha blockers or antimuscaranic

Artificial urinary sphincter

Sling

Drug treatment for erectile dysfunction such as PDE5I, MUSE or penile injections

Inflatable prosthesis or semi rigid prothesis

Vacuum pump

Treatment for hormone therapy side effects such as drugs for hot flushes, breast tenderness, treatment for depression or osteoporosis

Anti diarrhoea drugs for bowel issues

Other treatments relating to bowel or bladder side effects

No treatment for side effects

Other

Treatments for side effects other Please specify

Was the treatment received for your partner's side effects successful? *

What has been the impact of prostate cancer on your (and your partners) mental health and wellbeing? Please share details of any support you've received and things you did to help yourself *

What has been the impact of prostate cancer on your (and your partners) work and employment? Please share details of any support you've received and things you did to help yourself *

What has been the impact of prostate cancer on your relationships? Please share details of any support you've received and things you did to help yourself *

What has been the impact of prostate cancer on your sex life? Please share details of any support you've received and things you and your partner did to help yourselves *

Did your partner make any diet and lifestyle changes after treatment? *

Yes

If yes, please describe

Do you have any interests or hobbies that you're happy to share with us *

Are there any other subjects about your experience of prostate cancer you would be uncomfortable to talk about with a service user? *

Are there any other details about your experience of prostate cancer that you would like to share? *

Your data

Additional consent

I consent to you processing my health information provided above so that service users referred by the Prostate Cancer Specialist Nurses are matched appropriately to my volunteer role for One-to-one sessions.

I consent to you processing my health information *

Privacy

We will look after your details and we won’t share your data with anyone else. Read our Privacy Policy https://prostatecanceruk.org/privacy for more information.