YOUR PROSTATE CANCER SUMMARY NAME: __________________________________ Age________ Biopsy | Gleason___________ Date___________ Three most recent PSA levels & date(s) ______/______ ______/_______ ______/_____ Circle PCRI Stage: Sky Teal Azure Indigo Royal Learn your stage at pcri.org/stagingquiz BEST DESCRIPTION OF YOUR CURRENT SITUATION - check all that apply: My PSA is high, but I have not been diagnosed with prostate cancer. I have been diagnosed and I am deciding on a treatment. I have been diagnosed and I am on Active Surveillance. I have had treatment and I am in remission. I am experiencing side effects from treatment. I have had treatment (surgery, radiation, etc.) on __________and my PSA is rising. I have been on testosterone inactivating pharmaceuticals (TIP) and my PSA is rising. I have scans that show a few metastases but have had NO treatment. I have scans that show widespread metastases, and I have had NO treatment. I have been on TIP for __________ (months/years) and scans show a few metastases. I have been on TIP for __________ (months/years) and my scans show many metastases. CURRENT TREATMENT(S): _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ PREVIOUS TREATMENT(S)/Date(s): _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ Previous Treatment(s): Active surveillance, radical prostatectomy, IMRT, SBRT, proton therapy, HDR brachytherapy, permanent brachyther- apy, cryotherapy, high intensity focused ultrasound, electroporation, laser ablation, Lupron, Casodex, Eligard, Trelstar, Firmagon, Zolodex, other first generation hormone agent, Nubeqa, Zytiga, Xtandi, Erleada, Provenge, Keytruda, Taxotere, Jevtana, Carboplatin, Ketoconazole, Xofigo, Lutetium 177. Previous Scan(s)/Date(s): _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ Previous Scan(s): Multiparametric MRI, CT Scan, Bone Scan, Axumin PET, PSMA /PET LEARN MORE AT PCRI.ORG YOUR PROSTATE CANCER SUMMARY NAME: __________________________________ Age________ Biopsy | Gleason___________ Date___________ Three most recent PSA levels & date(s) ______/______ ______/_______ ______/_____ Circle PCRI Stage: Sky Teal Azure Indigo Royal Learn your stage at pcri.org/stagingquiz BEST DESCRIPTION OF YOUR CURRENT SITUATION - check all that apply: My PSA is high, but I have not been diagnosed with prostate cancer. I have been diagnosed and I am deciding on a treatment. I have been diagnosed and I am on Active Surveillance. I have had treatment and I am in remission. I am experiencing side effects from treatment. I have had treatment (surgery, radiation, etc.) on __________and my PSA is rising. I have been on testosterone inactivating pharmaceuticals (TIP) and my PSA is rising. I have scans that show a few metastases but have had NO treatment. I have scans that show widespread metastases, and I have had NO treatment. I have been on TIP for __________ (months/years) and scans show a few metastases. I have been on TIP for __________ (months/years) and my scans show many metastases. CURRENT TREATMENT(S): _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ PREVIOUS TREATMENT(S)/Date(s): _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ Previous Treatment(s): Active surveillance, radical prostatectomy, IMRT, SBRT, proton therapy, HDR brachytherapy, permanent brachyther- apy, cryotherapy, high intensity focused ultrasound, electroporation, laser ablation, Lupron, Casodex, Eligard, Trelstar, Firmagon, Zolodex, other first generation hormone agent, Nubeqa, Zytiga, Xtandi, Erleada, Provenge, Keytruda, Taxotere, Jevtana, Carboplatin, Ketoconazole, Xofigo, Lutetium 177. Previous Scan(s)/Date(s): _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ _________________________/_______ _________________________/________ Previous Scan(s): Multiparametric MRI, CT Scan, Bone Scan, Axumin PET, PSMA / PET LEARN MORE AT PCRI.ORG.