clinical research study | High Instensity Focused Ultrasound

Please complete the following medical screening questions below to determine your eligibility. Your information will not be shared with third parties and will remain private. Please read our privacy policy for more details. Thank you for your interest in the USHIFU research study. Please Note: You do not have to answer any particular question. However, your responses will be used to determine if you are a good match for our research study.

How did you find out about this study opportunity?


What is your name?

First	MI	Last

What is your date of birth?
dd-mm-yyyy
What is your zip or postal code?

Has your doctor told you that your prostate cancer has returned or recurred?
Yes No
Has your prostate cancer spread to other parts of your body?
Yes No Unsure
Have you been treated previously with External Beam Radiation Therapy or EBRT?
Yes No

Was your External Beam Radiation Therapy done 2 or more years ago?
Yes No Unsure

Please enter the date of your EBRT.
dd-mm-yyyy

Do you have a tube to help you urinate, called a urethral stent?
Yes No Unsure
Have you received other treatment for prostate cancer except for EBRT or hormone therapy? These might include treatments such as radiation pellets Green Light, Cryotherapy, or prostate surgery?
Yes No
Are you currently undergoing hormonal therapy, sometimes referred to as anti-androgen therapy?
Yes No Unsure

Do you currently take blood thinners such as coumadin (Warfarin), Plavix or any other anticoagulant?
Yes No

Within the past 3 months, have you taken any drugs such as Proscar (finasteride), or Avodart (dutasteride)?
Yes No
Are you currently being treated for an active urinary tract infection?
Yes No
Have you had any prior rectal surgeries except for hemorrhoids?
Yes No
Do you have a history of inflammatory bowel disease?
Yes No Unsure
Do you currently have bladder cancer?
Yes No
Do you have a history of any malignancies other than skin cancer?
Yes No
Do you have a urinary tract or rectal fistula?
Yes No