Prostate Cancer Case Report Form
Please fill out this form to document a prostate cancer case for clinical reporting purposes.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Sex
*
Male
Female
Other
Date of Diagnosis
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presenting Symptoms
*
Urinary frequency
Nocturia
Hematuria
Pelvic pain
Asymptomatic
Other
Prostate-Specific Antigen (PSA) Level at Diagnosis (ng/mL)
*
Imaging Findings
Biopsy/Pathology Report
*
Cancer Stage at Diagnosis
*
Please Select
Stage I
Stage II
Stage III
Stage IV
Unknown
Primary Treatment Modality
*
Surgery
Radiation therapy
Hormone therapy
Active surveillance
Other
Follow-up/Outcome
Reporting Clinician Name
*
First Name
Last Name
Reporting Clinician Email
*
example@example.com
Submit Case Report
Should be Empty: