Prostate Cancer Screening Form

Your Information

First Name

Last Name

Date of Birth

Current Age

Phone Number

Address

City

State

Zip Code

If Other, please specify.

Gender at Birth MaleFemale

Have you ever been diagnosed with prostate cancer? YesNoUnknown

Are you currently having any of the following symptoms?

Choose all that apply, hold SHIFT to select multiple.

Do you have a known genetic mutation associated with prostate cancer (i.e. BRCA1 or BRCA2)? YesNoUnknown

Do you have a family history of prostate cancer, particularly a first-degree relative (i.e. father or brother) that was diagnosed before the age of 65? YesNoDon't Know

Have you ever had a Prostate Specific Antigen (PSA) blood test? YesNoUnknown

Do you have a primary care provider? YesNo

If yes, name of primary care provider.

How did you hear about this cancer risk survey?

Choose all that apply, hold SHIFT to select multiple.

I Acknowledge and Consent that by submitting this form, you agree to understanding that this risk assessment is for educational and informational purposes only. It is not a medical diagnosis or treatment. Participation in this cancer screening program allows your information to be used to assess health risks and provide follow-up recommendations. Participation is also voluntary and can be withdrawn at any time. You must select this checkbox to submit this form.

Baptist Health Mission

Prostate Cancer Screening Form

Prostate Cancer Screening Form