Study Title: Evaluation of a Non-Toxic Medication in the Management of Prostate Cancer
Principal Investigator: Dr. Nakul Chandra, M.D., F.A.A.P., Pediatric Cardiologist
Location: Children’s Health & Welfare Foundation / RGS Trust Hospital
Purpose: To collect information from individuals interested in participating in a clinical trial for a non-toxic treatment approach to prostate cancer.
(All responses are confidential and used only for preliminary screening.)
Patient Information
Full Name: __________________________
Date of Birth / Age: __________________________
Gender: ☐ Male ☐ Other ☐ Prefer not to say
Email Address: __________________________
Phone Number: __________________________
City / State / Country: __________________________
Medical History
Date of prostate cancer diagnosis (if known): __________________________
How was diagnosis made? ☐ Biopsy ☐ MRI ☐ Ultrasound ☐ PSA test ☐ Other (please specify)
Have you had a prostate biopsy? ☐ Yes ☐ No
If yes, please describe the result (Gleason score, stage, etc.): ____________________________________
Have you had prostate surgery? ☐ Yes ☐ No If yes, type of surgery and date: ____________________
Are you currently receiving radiation therapy? ☐ Yes ☐ No
Are you on hormone therapy? ☐ Yes ☐ No If yes, name of drug and duration: ____________________
Are you taking any medications or supplements currently?
☐ Yes ☐ No If yes, list them: __________________________________________
Current Symptoms
How many times do you wake up at night to urinate?
☐ 0–1 ☐ 2–3 ☐ 4 or more
Urine flow: ☐ Strong ☐ Moderate ☐ Weak
Any pain, burning, or blood in urine? ☐ Yes ☐ No If yes, describe: _________________________
Do you have difficulty starting or stopping urination? ☐ Yes ☐ No
Do you feel incomplete emptying of the bladder? ☐ Yes ☐ No
Any weight loss, bone pain, or back pain? ☐ Yes ☐ No If yes, please describe: _______________
Lifestyle and Other Information
Diet pattern: ☐ Vegetarian ☐ Non-vegetarian ☐ Mixed
Do you smoke or drink alcohol? ☐ Yes ☐ No
Have you tried alternative or herbal treatments? ☐ Yes ☐ No If yes, which ones? _____________
Have you had any major illnesses in the past (diabetes, hypertension, heart disease)?
☐ Yes ☐ No If yes, please list: __________________________________________
Family history of prostate or other cancers? ☐ Yes ☐ No If yes, who and what type? ___________
Additional Comments
(Include any relevant medical reports, biopsy results, or questions you may have.)
Consent
☐ I understand that this form is for preliminary screening only and does not guarantee enrollment in the trial.
☐ I consent to be contacted by Dr. Nakul Chandra or his team regarding this study.
Signature (type full name): __________________________
Date: __________________________