Patient Intake Form

Surname

First Name

DOB (DD-MMM-YYYY)

Phone Number

Primary Email

Country

Home Address

City

Province / State

Postal Code

Date prostate cancer diagnosis (DD-MMM-YYYY)

Treatment for prostate cancer

Date of treatment (DD-MMM-YYYY)

New Field New Field Module 1 - Introduction to Prostate Cancer & Primary Treatment Options Module 2 - Managing the Impact of Prostate Cancer Treatment on Sexual Function & Intimacy Module 3 - Exercise for Prostate Cancer Patients Module 4 - Recognition and Management of Treatment Related Side Effects of Androgen Deprivation Therapy Module 5 - Pelvic Floor Physiotherapy for Bladder and Bowel Concerns Module 6 - Counselling Services Module 7 - Metastatic Disease Management Module 8 - Nutrition for Prostate Cancer Patients

How did you hear about the PCSC Program? How did you hear about the PCSC Program? Physician (please specify name below) Online search Friend Other (please specify below)

Name of physician or other referral source (if applicable)

I’d like to receive email from the PCSC Program, which may include newsletters, program updates, and other notifications. I’d like to receive email from the PCSC Program, which may include newsletters, program updates, and other notifications. Yes No