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Patient Questionnaire For MRI Prostate

Patient Name

D.O.B.

Date of Exam

Have you ever had x-ray or imaging studies of your prostate or pelvis?

Yes No

Please describe when and where:

Results:

Have you ever had a biopsy of your prostate?

Yes No

Please describe when and where:

Results:

Have you ever had previous prostate or bladder surgery?

Yes No

Please describe when and where:

Results:

Your current PSA?

Has there been any therapy for prostate cancer?

Yes No

Please describe the type of therapy: