Bladder Study

Bladder Study

Catheterization Suitability Questionnaire
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Doctor Name

First NameLast Name
Doctor Practice Name
Doctor Phone Number
Please enter a valid phone number.
Age

18-3940-5555+
Sex
Do you use a Catheter?

YesNo
If yes, diagnosis/purpose of catheterization
Have you ever attempted self-catheterization?

YesNo
If yes, how many times have you attempted self-catheterization?

1-2 Times3-5 TimesMore than 5 times
How would you rate your overall experience with self-catheterization?

Very positiveSomewhat positiveNeutralSomewhat negativeVery negative
What challenges did you face during your attempts? (Select all that apply)

Physical discomfortDifficulty in techniqueAnxiety or nervousnessLack of confidenceOther
Did you receive any training or education on self-catheterization before your attempts?

YesNo
Did you receive support from healthcare professionals during your attempts?

YesNo
On a scale of 1 to 10, how comfortable do you feel performing self-care procedures on your own? - 1 (Not comfortable at all) to 10 (Highly comfortable)
By submitting your personal identifying information through this form, you acknowledge and agree to the following: The information you provide will be used solely for the purpose of qualifying you for a clinical trial and your information will be handled in accordance with our Privacy Policy. You are not required to submit any information, but doing so may be necessary to receive certain services or information. We will not sell, trade, or rent your personal information to third parties.*
Thank you for completing this questionnaire! Your feedback is valuable in determining your suitability for participation in the study.
Should be Empty: