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

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Give specific history of your prostate and general health conditions.