VA Benefits Consultants
Prostate Cancer Disability Benefits Questionnaire
Please Specify your condition:
Please answer the following questions related to your disease.
a) When did you first experience the symptoms of your condition (e.g., during service etc.)?
b) How long have you had this condition?
c) Have your symptoms gotten worse over time?
Please indicate status of the disease?
Active | Remission |
Prostate Cancer Questionnaire
Section I – Treatment
Have you completed any treatment for prostate cancer or are you undergoing any treatment for prostate cancer? (If yes, please specify treatment type)
Yes
No, watchful waiting
Treatment completed currently in watchful waiting | Surgery |
Undergone Prostatectomy
Radical Prostatectomy | Transurethral resection Prostatectomy | Other |
In case if you have opted any other treatment process:
Other surgical procedure:
Date of surgery:
Radiation therapy (Please specify date of completion or anticipated date of completion):
Brachytherapy (Please specify date of treatment):
Chemotherapy therapy (Please specify date of completion or anticipated date of completion):
Hormonal therapy (Please specify date of completion or anticipated date of completion):
Any other treatment (Please describe with date of procedure and date of completion or anticipated date of completion):
Section II – Voiding Dysfunction
(Please skip this section if do not have this condition)
Does the voiding dysfunction require use of an appliance (catheter etc.)?
Yes | No |
If yes, specify the appliance:
Does the voiding dysfunction cause increased frequency of urination?
Yes | No |
If yes, check all that apply:
Daytime urination interval between 2 and 3 hours
Daytime urination interval less than 1 hour
Nighttime awakening to urinate 3 to 4 times
Daytime urination interval between 1 and 2 hours
Nighttime awakening to urinate 2 times
Nighttime awakening to urinate 5 or more times
Daytime urination interval between 2 and 3 hours | Daytime urination interval between 1 and 2 hours | ||
Daytime urination interval less than 1 hour | Nighttime awakening to urinate 2 times | ||
Nighttime awakening to urinate 3 to 4 times | Nighttime awakening to urinate 5 or more times |
Does the voiding dysfunction cause any of these signs or symptoms of obstructed urination? (Check all that apply):
Hesitancy to urinate
Slow or weak stream
Decreased force of stream
Recurrent urinary tract infections due to obstruction in urination
Urinary retention requiring intermittent catheterization
Urinary retention requiring continuous catheterization
Uroflowmetry peak flow rate less than 10cc/sec
Post-urination residuals greater than 150cc
Hesitancy to urinate | Slow or weak stream | ||
Decreased force of stream | Recurrent urinary tract infections due to obstruction in urination | ||
Urinary retention requiring intermittent catheterization | Urinary retention requiring continuous catheterization | ||
Uroflowmetry peak flow rate less than 10cc/sec | Post-urination residuals greater than 150cc |
Check if you have stricture disease (blockage of urine) requiring dilatation. If checked, indicate frequency of periodic dilation:
1 to 2 times per year | Every 2 to 3 months | Other |
Specify if you have other frequency of periodic dilation:
Describe any other signs or symptoms of obstructed urination caused by the voiding dysfunction:
Section III – Erectile Dysfunction
(Only complete this section if you are diagnosed with this condition)
What do you think causes erectile dysfunction?
Indicate which diagnosis is erectile dysfunction attributable to (at least a 50% probability):
Are you able to achieve an erection sufficient for penetration and ejaculation without medication?
Yes | No |
If no, have you used any medications for treatment of your erectile dysfunction?
Yes | No |
If yes, are you able to achieve an erection sufficient for penetration and ejaculation with medication?
Yes | No |
Section IV – Urinary tract/ Kidney Infection
(Please skip this section if you do not have this condition)
Do you have a history of recurrent symptomatic bladder or urethral infections diagnosed by a doctor?
Yes | No |
If you had recurrent infections, indicate all treatment used:
No treatment
Hospitalization for 1 time or 2 times per year
Hospitalization for more than 2 times per year
Other (Describe Below)
No treatment | Hospitalization for 1 time or 2 times per year | ||
Hospitalization for more than 2 times per year | Other (Describe Below) |
If you have checked other option then please describe that here:
Long-term drug therapy (If checked, list medications):
Drainage (If checked, indicate dates when drainage performed over past 12 months):
Continious entensive management (If checked, indicate type of treatment and medications used over past 12 months):
Intermittent intensive management (If checked, indicate type of treatment and medications used over past 12 months):
Do you have any scars related to this condition? If so, are any of the scars painful?
Describe in detail how does this condition affect your ability to work?
Dated:
SIGNED:
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