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MRI PROSTATE QUESTIONNAIREDOES THE PATIENT HAVE CROHN’S DISEASE?YES ????????NO ?????????DOES THE PATIENT HAVE ULCERATIVE COLITIS?YES ????????NO ????????HAS THE PATIENT HAD RADIATION OR SURGERY OF THE PROSTATE OR PELVIC FLOOR WITHIN THE LAST 8 WKS?YES ????????NO ????????HAS THE PATIENT HAD RADIATION OR SURGERY OF THE RECTUM OR SURROUNDING AREA WITHIN THE LAST 8 WKS?YES ????????NO ????????DOES THE PATIENT HAVE A RECTAL FISTULA?YES ????????NO ????????DOES THE PATIENT HAVE SEVERE HEMORRHOIDS?YES ????????NO ????????DOES THE PATIENT HAVE STRICTURE OF THE ANAL CANAL?YES ????????NO ????????HAS THE PATIENT HAD RADIATION SEEDS WITHIN THE LAST 12 WKS?YES ????????NO ????????HAS THE PATIENT HAD A BIOPSY OF THE PROSTATE WITHIN THE LAST 5 WKS?YES ????????NO ????????WHAT IS THE PATIENT’S PSA LEVEL?????????????????????? ................
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