The Prostate Net®
P. O. Box 2192
Secaucus, NJ 07096
Tel: 888.477.6763
Fax: 270.294.1565

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To receive access to the symposium's SPOUSE/PARTNER 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 played more of a significant role that lead to initial screening:

The patient
Me as a spouse/partner

What was the primary therapy of your spouse/partner:

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

Has his disease progressed since his first treatment:

Yes
No

His current treatment includes:

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

Does he have any side effects from his treatment?

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

How have these side effects affected your life together:

I go with him for his regular check-ups with his doctor
Our sex life has decreased
We have changed how we are intimate with each other
I attend support groups to communicate with others
No impact at all