NEWLY DIAGNOSED WORKSHEET
INFORMATION ABOUT YOUR PROSTATE CANCER Use this worksheet to keep track of basic information about your prostate cancer diagnosis as you need in order to make your decisions about your care. Date of diagnosis ________________________ PSA level at diagnosis ________________________ Gleason score __________________________________ Grade Group _________________________ Risk Group: Very Low/Low Intermediate Favorable Intermediate Unfavorable High Very High Number of biopsy samples taken ________________________________________________________ Number of biopsy samples containing cancer _____________________________________________ Stage at diagnosis (I-IV) _________________________________________________________________ Nodal involvement? Yes No My cancer is: Localized (only in the prostate) Locally advanced (spread to just outside the prostate) Advanced or Metastatic (spread to other organs or parts of the body) Location of metastasis (spread) _____________________________________
Date
Follow-up Tests
Results
_____________________ _____________________ _____________________ _____________________
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CT Scan
MRI
PET or PET/CT Scan ______________________________________________________
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Other tests
PHYSICIANS Prostate cancer diagnosed by: Name: ______________________________________ Contact information: ______________________ Other doctors or healthcare providers seen: Name: ______________________________________ Contact information: ______________________ Name: ______________________________________ Contact information: ______________________ Other important numbers: ________________________________________________________________ ZERO Prostate Cancer provides this information as a service. It is not intended to take the place of medical professionals or the recommendations of your healthcare team. Consult your healthcare team if you have questions about your specific care. LEARN MORE We encourage you to use this information in conversations with your healthcare team about prostate cancer and related topics. For more information about prostate cancer and ZERO Prostate Cancer, visit our website zerocancer.org/learn .
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