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:
    LightModerateSevere


    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.