Questionnaires

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Condition-Specific Questionnaires

Help us diagnose and manage your condition

Pre-Admission Questionnaires

Required before coming to hospital for surgery

 

These questionnaires help us gather information on you and your condition. Filling out the appropriate questionnaires before coming to your office visit can greatly speed up your visit. How to fill out these forms so they can be saved on your computer.

 

Questionnaire Button

 

REQUIRED FOR ALL PATIENTS. Please ensure that you complete the questionnaire in full, especially the allergy and medication section. Your Family Physician may be able to help you if you have any difficulty completing the questionnaire. If you would like to print and fill-out by hand, download this version.

 

Condition-specific Questionnaires - What Are You Seeing Us For?


Some of the questionnaires are self explanatory. Pick more than one questionnaire if you need to. Print, fill out and fax, mail or bring to your visit.

 

Questionnaire
 Who Should Complete It

 

Computer-completable version

International Inventory of Erectile Function - Short Form
Sexual Health Inventory for Males

  • For males with
  • Any urinary problems
  • Prior or planned prostate surgery
  • Abnormality on prostate exam or PSA
  • Your family doctor is concerned regarding the presence of prostate cancer because:

    • Your PSA is elevated
    • You have an abnormally feeling prostate
    • You have a strong family history of prostate cancer

    Computer-completable version

    International Inventory of Erectile Function - Long Form

    For males whose primary complaint is erectile dysfunction

     

    International Prostate Symptom Score (AUASS) and International Inventory of Erectile Function - Short Form
    Sexual Health Inventory for Males

    Please note that we ask about erectile function because it is related to urinary symptoms and may be affected by treatment for urinary symptoms.

    For men with

  • Any urinary problems
  • Prior or planned prostate surgery
  • Abnormality on prostate exam or PSA
  • For women with problems urinating including:

    • Urinary incontinence (leakage)
    • Urinary frequency

    For men and women who

  • Need to urinary frequently
  • Have urinary incontinence (leakage)
  • PLEASE COMPLETE IF YOU ARE BEING SEEN FOR FREQUENT URINATION AT NIGHT (nocturia)
  • For men having difficulty conceiving.

     

            

     

    Don't worry if you don't see your problem here because not all conditions have validated questionnaires. We have only included standardized questionnaires for the most common conditions. Why all the paperwork? Validated questionnaires are useful in urologic conditions for diagnosis, directing treatment, assessing the severity of a condition and response to treatment. In some circumstances, they offer a more objective view of your problem than a clinical interview might.

     

    Pre-Admission Questionnaires

    These are required by the hospital prior to hospital admission for surgery. YOU DO NOT NEED TO FILL THESE OUT PRIOR TO CYSTOSCOPY IN AMBULATORY CARE. If you have filled out the Clinic Pre-Visit Questionnaire in the Richmond office within the last year, you do not need to fill out this questionnaire if you are coming for surgery at Richmond Hospital or Vancouver General Hospital unless there has been a change in your health status.


    PICK THE QUESTIONNAIRE FOR THE HOSPITAL YOU ARE HAVING SURGERY AT.

     

       

     

    RH = Richmond Hospital; VGH = Vancouver General Hospital

     

    Saving completed questionnaires on your computer

    We suggest that you save the any questionnaires that you complete on your computer.  You can use them to keep track of your important medical information and quickly update them if there have been any changes since your last visit with us or prior to seeing other health care providers.

    To save the completed questionnaire on your computer

    1. Click on the questionnaire to download to your browser
    2. SAVE THE QUESTIONNAIRE TO YOUR COMPUTER BEFORE YOU FILL IT IN
    3. Open the questionnaire in Adobe Acrobat, complete and save

    IMPORTANT: if you complete the questionnaire in your web browser, you will be able to print it out but you will NOT be able to save it.

     

    Author(s): K Poon  Major Revision/Review: January 2011