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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
No

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: *

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.

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.

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

Side effects other Please specify

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

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
No

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

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I consent to you processing my health information *

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