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 Name Last Name

Date *

Month Day Year

Birthday *

Month Day Year

Phone Number *

Area Code Phone Number

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

1 - Very Low 2 - Low 3 - Moderate 4 - High 5 - 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 none 2 - 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 none 2 - 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 difficult 2 - Very difficult 3 - Difficult 4 - Slightly difficult 5 - Not difficult

When you attempted sexual intercourse, how often was it satisfactory for you? *

1 - Extremely difficult 2 - Very difficult 3 - Difficult 4 - Slightly difficult 5 - 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/Medication Vacuum device Injection therapy MUSE

How long ago did you complete your prostate cancer treatment? *

Years, Months

Do you experience urine leakage? *

Yes No

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)

Do you wear pads or diapers, use a urine collection device or a penile clamp? (Check all that apply) *

Pads Diapers Urine collection device Penile Clamp

How many pads do you wear per day? *

How many diapers do you wear per day? *

On a scale of 0 to 5, with 0 being no bother and 5 being extreme bother, how bothered are you by your bladder control symptoms? *

	1	2	3	4	5

1 is No Bother, 5 is Extreme Bother

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.

Prostate Cancer Survivorship Questionnaire

Bladder Health Assessment