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Colorado CyberKnife Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC‐CP)

Page One

A Clinical Tool to Measure Urinary, Bowel, Sexual and Vitality/Hormonal Health
Patient Information:
calendar
Patients: Please answer the following questions by checking the appropriate checkbox. All questions are about your health and symptoms in the LAST FOUR WEEKS. Select one answer for each question.
1. Overall, how much of a problem has your urinary function been for you? *This question is required.
No problemVery small problemSmall problemModerate problemBig problem
2. Which of the following best describes your urinary control?   *This question is required.
Total control
0		Occasional dribbling
1		Frequent dribbling
2		No urinary control
4
3. How many pads or adult diapers per day have you been using for urinary leakage? *This question is required.
None
0		One pad per day
1		Two pads per day
2		Three or more pads per day
4
4. How big a problem, if any, has urinary dripping or leakage been for you?   *This question is required.
No problem
0		Very small problem
1		Small problem
2		Moderate problem
3		Big problem
4
5. How big a problem, if any, has each of the following been for you? *This question is required.
Space Cell No problem
0		Very small problem
1		Small problem
2		Moderate problem
3		Big problem
4
a. Pain or burning with urination
b. Weak urine stream/incomplete bladder emptying
c. Need to urinate frequently
6. How big a problem, if any, has each of the following been for you? *This question is required.
Space Cell No problem
0		Very small problem
1		Small problem
2		Moderate problem
3		Big problem
4
a. Rectal pain or urgency of bowel movements
b. Increased frequency of your bowel movements
c. Overall problems with your bowel habits
7. How would you rate your ability to reach orgasm (climax)?   *This question is required.
Very good
0		Good
1		Fair
2		Poor
3		Very poor to none
4
8. How would you describe the usual quality of your erections?   *This question is required.
Firm enough for intercourse
0		Firm enough for masturbation and foreplay only
1		Not firm enough for any sexual activity
2		None at all
4
9. Overall, how much of a problem has your sexual function or lack of sexual function been for you?   *This question is required.
No problem
0		Very small problem
1		Small problem
2		Moderate problem
3		Big problem
4
10. How big a problem, if any, has each of the following been for you? *This question is required.
Space Cell No problem
0		Very small problem
1		Small problem
2		Moderate problem
3		Big problem
4
a. Hot flashes or breast tenderness/enlargement
b. Feeling depressed
c. Lack of energy
0%
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