PSA Screening Questionnaire

Your details

First Name *

Last Name *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Is this your first PSA blood test

Yes

Note

In order for your blood test to be as accurate as possible you must not:

Have an active urine infection or prostatitis
Have had a proven urine infection in the last 6 weeks
Ejaculate in the 72 hours before your blood test
Exercise vigorously in the 48 hours before your blood test
Have had a prostate biopsy in the last 6 weeks

Please call the surgery on 0131 537 4407 to book a GP appointment to discuss this and close this form.

Do you have blood in your urine?

Yes

Please call the surgery on 0131 537 4407 to book a GP appointment to discuss this and close this form.

Have you had ANY of the symptoms listed below

Yes

Increased frequency of passing urine
Increased urgency to pass urine
Increased need to pass urine overnight
Slow urinary stream
Difficulty passing urine
Difficulty initiating urination
Blood in urine
Erectile dysfunction
Blood in semen

Have you had these symptoms for more than 4 weeks?

Yes

Please call the surgery on 0131 537 4407 to book a GP appointment to discuss this and close this form.

Do ANY of the following apply to you?

Yes

I have a first degree relative (father or brother) who has or has had prostate cancer?
I am of black or mixed black ethnicity?
I am a known carrier of a BRCA gene variant?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

If you are human, leave this field blank.