Prostate Health Check | St Josephs Hospital

First Name *

Surname *

Date of Birth *

Ethnicity *

Full Address *

Email *

Telephone Number *

GP Details *

Have you had a PSA test in the last 3 months.?

If Yes What was the value

What are your symptoms? *

Do you have the sensation of not emptying your bladder? Yes No

Do you have to urinate less than every 2 hours? Yes No

Do you have difficulty postponing urination (holding your bladder)? Yes No

Do you have a weak urinary stream? Yes No

Do you have to strain to start urination? Yes No

Do you get up more than once in the night to urinate? Yes No

Do you have a family history of prostate cancer? Yes No

Patient Prostate Health Check Form