Prostate cancer risk questionnaire

Prostate Cancer Risk Questionnaire

Please confirm if you have any of the following risk factors:

Aged over 50

Family history of prostate cancer (father/brother etc.)

Black or mixed race ethnicity aged over 45

Before submitting the form and requesting a blood test, please read the below information leaflet:

Confirmation *

I confirm that I have no urinary tract symptoms (such as blood in urine, poor stream etc).

I confirm that I have read the above information leaflet and wish to request a PSA prostate blood test.

I confirm that I am happy to have the blood test arranged, and to avoid cycling or sexual activity for 72 hours beforehand.

If your result is raised, you may need a repeat test or an appointment with a clinician to discuss a referral to the hospital for further tests.

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