Prostate Health Maintenance Form
Please complete this form to help monitor and maintain your prostate health. Your responses will assist healthcare providers in assessing risk factors and recommending appropriate care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever been diagnosed with a prostate condition?
*
No
Yes, benign prostatic hyperplasia (BPH)
Yes, prostatitis
Yes, prostate cancer
Other
Do you have a family history of prostate cancer?
*
No
Yes, father
Yes, brother
Yes, other relative
Have you experienced any of the following urinary symptoms recently?
*
Frequent urination
Difficulty starting urination
Weak urine stream
Blood in urine
Painful urination
None of the above
When was your last prostate screening (PSA test or digital rectal exam)?
*
Please Select
Never
Within the past year
1-2 years ago
More than 2 years ago
Are you currently taking any medications for prostate health?
*
No
Yes, prescription medication
Yes, over-the-counter supplements
Other
How would you rate your current prostate health?
1
2
3
4
5
Please describe any additional symptoms or concerns related to your prostate health.
Do you follow any of these lifestyle habits?
Regular exercise
Healthy diet (low fat, high fiber)
Smoking
Alcohol consumption
None of the above
Submit
Should be Empty: