Comprehensive Evaluation Day Worksheet
(to be completed before consultation appointment is made)
Medical Record Items Required for Consultation
1. A completed American Urological Association (AUA)
Symptom Score Sheet
2. Biopsy reports (If a consult visit is scheduled
at the center,
pathology slides need to be sent for review.)
3. Prostate Specific Antigen (PSA) blood test results
(the official laboratory reports)
4. The physician's notes regarding the cancer
5. Reports of any X-rays and Bone/CT/MRI Scans
6. Reports of Prostate Ultrasound examinations
7. Copy of patient demographic and insurance cards
(both sides)
8. New patient registration form
9. Sexual Health Inventory Expanded Prostate Index Composite (EPIC) Score Sheet
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