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Microsoft word - epic - prostate cancer qol questionnairedupont .doc

Please be sure to answer ALL pages
Over the past 4 weeks, how often have you leaked urine? 1. Rarely or never Over the past 4 weeks, how often have you urinated blood? Over the past 4 weeks, how often have you had pain or burning with urination? 1. Rarely or never Which of the following best describes your urinary control during the last 4 weeks? 1. Total control How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks? Overall, how big a problem has your urinary function been for you during the last 4 weeks? 1. How often have you had rectal urgency (felt like I had to pass stool, but did not) during the last 4 weeks? How often have you had uncontrolled leakage of stool or feces? How often have you had stools (bowel movements) that were loose or liquid (no form, watery, mushy) during the past 4 weeks? 1. How often have you had bloody stools during the last 4 weeks? 1. How often have your bowel movements been painful during the last 4 weeks? 1. How many bowel movements have you had on a typical day during the last 4 weeks? 1. Two or less 2. Three to four 3. Five or more How often have you had crampy pain in your abdomen, pelvis or rectum during the last 4 weeks? 1. Rarely or never Increased urgency of Bowel movements…. Overall, how big a problem have your bowel habits been for you during the last 4 weeks? 1. No problem How would you describe the usual QUALITY of your erections during the last 4 weeks? 1. Firm enough for intercourse 3. Not firm enough for any sexual activity 2. Firm enough for masturbation/foreplay How would you describe the FREQUENCY of your erections during the last 4 weeks? 1. Had an erection whenever I wanted one 4. Had an erection less than half the time 2. Had an erection more than half the time 5. Never had an erection when I wanted one During the last 4 weeks, how often did you have sexual activity? 1. Daily Overall, how would you rate your ability to function sexually during the last 4 weeks? 1. During the past 3 months, have you ejaculated any blood? 1. No 2. Yes During the past 3 months, have you had painful ejaculation? 1. No 2. Yes, mild but no big problem 3. Yes, moderate but can still have sex relations 4. Yes, severe - hurts too badly to have sex During the past 3 months, have you used any of these sexual aids? 1. None Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks? 1. None Are you taking any of these medications? 8. Blood thinners such as Plavix and/or aspirin 4. Urospas, Ditropan, Probanthine, Levbid, Detrol 10. Saw Palmetto, Prostata 5. Flomax, Uroxatrol, Cardura or Hytrin 6. Hormone shots (Lupron, Zoladex, Eligard) During the past 6 months, have you had any surgical procedures on the prostate or rectum? Over the past 6 months, have you developed high blood pressure or diabetes? 1. No 2. High blood pressure 3. Diabetes 4. Both Over the past 6 months, have you developed any other serious medical problem?

Source: http://www.wilmetteradiationoncology.com/pdf/Prostate_Cancer_QoL_Questionnaire.pdf

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