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Men’s Urology Catheter-Free Program
Men’s Urology Catheter Free Program Patient Consultation Form
Men’s Urology Catheter Free Program Patient Consultation Form
Patient Information:
First Name
Last Name
Date of Birth
Email Address
Phone Number
County of Residence
Cuyahoga
Lake
Lorain
Summit
Portage
Ashland
Ashtabula
Geauga
Other County of Residence not Listed Above
Gender
Male
Female
Non Binary
Prefer not to say
Race / Ethnicity
Catheter & Urinary Retention Screening:
Do you currently have a urinary catheter in place?
Yes
No
If yes, when was the catheter first placed?
Was the catheter placed by a University Hospitals (UH) provider?
Yes
No
Not sure
Have you ever tried to have the catheter removed (a voiding trial)?
Yes – successful
Yes – unsuccessful
No
Not sure
Have you been told you have any of the following? (check all that apply)
Enlarged prostate / BPH
Acute urinary retention (AUR)
Chronic urinary retention
Distended bladder
Urinary tract infections
Blood in urine
None / Not sure
How would you prefer to start this discussion?
Virtual (telehealth) visit with a Urology Nurse Practitioner
In person appointment with a Urology Nurse Practitioner
No preference
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