EPIC

The Expanded Prostate Cancer Index Composite

This questionnaire is designed to measure Quality of Life issues inpatients with prostate cancer. To help us get the most accurate measurement, it is important that you answer all questions honestly and completely. Please take the time to read and answer each question and circle the answer that best represents your response. Remember, as with all medical records, information contained within this survey will remain strictly confidential.

Last Name Middle Name Initial First Name

Email: Procedure:

Latest PSA value: Date Drawn: Month : Day : Year:

Pre-op

Post-op
1 Month 3 Months 6 Months 9 Months 12 Months 13 Months 24 Months

Surgery Date: Month : Day : Year:

Surgeon:

Date of Birth:
Month : Day : Year:

Race: Height: ft. in. Weight: lbs.

Are you involved in the following clinical trial?
Effect of Viagra on return of erectile function after Nerve-sparing Laparoscopic Radical Prostatectomy
Yes No

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