EPIC - 26

The Expanded Prostate Cancer Index Composite

This questionnaire is designed to measure Quality of Life issues in patients with Prostate cancer. To help us get the most accurate measurement, it is important that you answer all questions honestly and completely.

Remember, as with all medical records, information contained within this survey will remain strictly confidential.

Today's Date (please enter date when survey completed)

Date

Name

Date of Birth

1. Over the past 4 weeks, how often have you leaked urine?

      More than once a day
      About once a day
      More than once a week
      About once a week
      Rarely or never

2. Which of the following best describes your urinary control during the last 4 weeks?

      No urinary control whatsoever
      Frequent dribbling
      Occasional dribbling
      Total control

3. How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks?

      None
      1 pad per day
      2 pads per day
      3 or more pads per day

4. How big a problem, if any, has each of the following been for you during the last 4 weeks?

a. Dripping or leaking urine

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

b. Pain or burning on urination

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

c. Bleeding with urination

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

d. Weak urine stream or incomplete emptying

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

e. Need to urinate frequently during the day

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

5. Overall, how big a problem has your urinary function been for you during the last 4 weeks?

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

6. How big a problem, if any, has each of the following been for you?

a. Urgency to have a bowel movement

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

b. Increased frequency of bowel movements

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

c. Losing control of your stools

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

d. Bloody stools

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

e. Abdominal/ Pelvic/Rectal pain

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

7. Overall, how big a problem have your bowel habits been for you during the last 4 weeks?

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

8. How would you rate each of the following during the last 4 weeks?

a. Your ability to have an erection?

      Very Poor to None
      Poor
      Fair
      Good
      Very Good

b. Your ability to reach orgasm (climax)?

      Very Poor to None
      Poor
      Fair
      Good
      Very Good

9. How would you describe the usual QUALITY of your erections during the last 4 weeks?

      None at all
      Not firm enough for any sexual activity
      Firm enough for masturbation and foreplay only
      Firm enough for intercourse

10. How would you describe the FREQUENCY of your erections during the last 4 weeks?

      I NEVER had an erection when I wanted one
      I had an erection LESS THAN HALF the time I wanted one
      I had an erection ABOUT HALF the time I wanted one
      I had an erection MORE THAN HALF the time I wanted one
      I had an erection WHENEVER I wanted on

11. Overall, how would you rate your ability to function sexually during the last 4 weeks?

      Very Poor to None
      Poor
      Fair
      Good
      Very Good

12. Overall, how big a problem has your sexual function or lack of sexual function been for you during the last 4 weeks?

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

13. How big a problem during the last 4 weeks, if any, has each of the following been for you?

a. Hot flashes

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

b. Breast tenderness/enlargement

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

c. Feeling depressed

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

d. Lack of energy

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

e. Change in body weight

      No Problem
      Very Small Problem
      Small Problem
      Moderate Problem
      Big Problem

EPIC

EPIC - 26

The Expanded Prostate Cancer Index Composite

THANK YOU VERY MUCH!!

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