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Fax: 270.294.1565

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To receive access to the symposium's PATIENT resource portal, please insert your e-mail address and then answer this short questionnaire. Mandatory inputs are marked with a *.
Once the survey is completed, click on submit and a link that will allow access to the symposium resources will be sent to the e-mail address you provide.

EMAIL: *

Who/what played the most significant role that lead to your initial screening for prostate cancer:

It was my decision to be screened
My spouse/partner initially encouraged me to be screened
My physician encouraged the screening
The screening was a part of a routine physical

My primary therapy was:

Surgery
Radiation
Drug therapy
Active surveillance/watchful waiting
Natural/alternative medicine

Has your disease progressed since your first treatment:

Yes
No

My current treatment includes:

Hormone treatment
Radiation
Chemotherapy
Natural/alternative medicine
Active surveillance
Vitamins
Not currently being treated

Do you have any side effects from your treatment:

Erectile problems
Incontinence/urinary problems
Fatigue
Anemia
Heart problems
Pain
No side effects at this time

What lead to your original diagnosis of prostate cancer?

Regular check-up with my doctor
PSA test at a health fair or public screening
I was having symptoms/problems that had me see a doctor
I had an abnormal PSA test
A spouse/partner/friend encouraged me to get tested

Have you ever participated in a clinical trial:

Yes
No

Have you participated in any type of medical study:

Yes
No

Have you ever been offered information on clinical trials or medical study:

Yes
No