Form 4 Prostate Cancer Recurrence Questionnaire (PCRQ)

Attachment 5: Prostate Cancer Recurrence Questionnaire

OMB #: 0925-0407

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0407). Do not return the completed form to this address.

Expiry Date: xx/xx/xxxx

1. Since you were diagnosed and treated for prostate cancer in YEAR, has a doctor told you that the prostate cancer has come back or spread?

Yes  No 

If yes, when was this first discovered:

MONTH YEAR

2. Since you completed your treatment for prostate cancer in YEAR, what was the value of your HIGHEST PSA test result (ng/ml)?

Undetectable or less than 0.2 

0.2 to 0.9 

1 to 3.9 

4 to 9.9 

10 to 19.9 

20 or more 

Level was normal, but do not know exact value 

Level was high, but do not know exact value 

Don’t know 

In what year did your PSA show this result : _______ YEAR

3. Since you completed your treatment for prostate cancer in YEAR, what was the value of your MOST RECENT PSA test result (ng/ml)?

Undetectable or less than 0.2 

0.2 to 0.9 

1 to 3.9 

4 to 9.9 

10 to 19.9 

20 or more 

Level was normal, but do not know exact value 

Level was high, but do not know exact value 

Don’t know 

In what year did your PSA show this result: _______ YEAR

4. Since you completed your treatment for prostate cancer in YEAR, have you had any of the following tests? (Check all that apply.)

Biopsy 

MRI/CT Scan 

Bone Scan 

5. Did any of these tests show that the prostate cancer came back or spread?

Biopsy  YEAR __________

MRI/CT Scan  YEAR __________

Bone Scan  YEAR __________

6. Since you completed your treatment for prostate cancer YEAR, did you have any more treatment for prostate cancer (radiation, surgery, or chemotherapy)?

 YES  NO

7. If YES:

In what year did the treatments begin: YEAR_______

Did your PSA improve after this treatment?  YES  NO

7a. What was that treatment? (Indicate all that apply.)

Radiation Therapy to Pelvis 

Radiation Therapy to the bones 

Prostate Removal 

Hormone Ablation 

Chemotherapy 

6. What is the name, phone number and address of the physician who is caring for you for prostate cancer?

Same as above 

Name:_________________________________ Phone: ( )___________________

Address:______________________________________________________________

_______________________________________________________________

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