General Survey - Urology PCA Management

Please answer to the best of your knowledge considering the last year of your practice

Date

YYYY

Urologist

First Name

Last Name

Age

Please describe your Practice setting

Name of your Multispecialty or Urological Group

Number or Hospital and/or Ambulatory Affiliations

Go to Hospital

Please indicate the Hospital you do most cases

Other Hospitals - Ambulatory

Number of Prostate Biopsies a month

Number of New Prostate Cancer Diagnosis a month

Preferred Modality of Management for Low Risk Prostate Cancer

Preferred Modality of Management for Intermidiate Risk Prostate Cancer

Preferred Modality of Management for High Risk Prostate Cancer

Age >70, 1-4 cores positive PSA<15, Gleason 7-10

Age 60 to 70, 2-5 cores positive PSA<15, Gleason 6 or 7

Practice Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Years in Practice