Prostate Assessment Form

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    Prostate Information

    Past Treatment(s)
    Hormone TherapyRadiation TherapyChemotherapySeed ImplantProstatectomyPC Spes
    Current Treatments
    Hormone TherapyRadiation TherapyChemotherapySeed ImplantHerbal RemediesPC Hope

    Additional Information

    Rate your exposure to automobile exhaust:

    Check Current and Past Symptoms

    AllergiesAsthmaAthlete's FootBad BreathBladder InfectionsBody OdorChronic FatigueColitisCoated TongueConstipationDiabetesDiarrheaDiverticulitisEnlarged BreastsSalt, Fat, Sugar CravingsFungal Nails & ToenailsGas/BloatingHeartburnHeart PalpitationsHeart (skipping beats)InfectionIrritable Bowel SyndromeLeg CrampsLack of LibedoLow Blood SugarTender NipplesPainPuffy EyesSinusSpastic ColonStomach BloatingUlcersUrinating Difficulty

    Yes, send me emails, Newsletters, notice of special promotions and updates.

    Give specific history of your prostate and general health conditions.