Southwest Urology Associates

Name

What were you treated for?

Of your treatment options, which did you have done?

Did the treatment meet or exceed your expectations?

Exceeded Expectations
Met Expectations
Did Not meet expectations

How would you rate your condition PRIOR to treatment?

Poor
Worse than Normal
Normal
Better than Normal
Great

How would you rate your condition AFTER treatment?

Poor
Worse than Normal
Normal
Better than Normal
Great!

How would you rate the results of your treatment?

80% improvement or better
Greater than a 50% improvement
At least a 50% improvement
Less than a 50% improvement
No change or Not applicable

If you were treated with a nerve test, are you interested in learning more about and scheduling the surgery?

Yes
No
This does not apply to me

Would you like to leave any Comments?

Can Southwest Urology Associates use the information you provided as a resource for other patients on our website?

Yes
No

How would you like to be identified?

You may use my first name and last initial.
You may use my initials.
You may use the information provided but I'd like to remain anonymous.

Would you be interested in discussing your experience and outcomes with other patients?

Yes
No