urosurveyurinsexfunc.ascx

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                        <td height="20">2</td>
                        <td>When I leaked, it was only a few drops</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">3</td>
                        <td>When I leaked, it was less than a tablespoon</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">4</td>
                        <td>When I leaked, it was more than a tablespoon</td>
                      </tr>
                    </table></td>
                  <td>&nbsp;</td>
                  <td width="20"><strong>5.</strong></td>
                  <td width="270"><strong>During the last four (4) weeks, how 
                    often were you able to get an erection during sexual activity?</strong><br> 
                    <br> <table width="270" border="0" cellspacing="0" cellpadding="0">
                      <tr valign="top"> 
                        <td width="30" height="20">1</td>
                        <td width="240">No sexual activity</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">2</td>
                        <td>Almost never / never</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">3</td>
                        <td>A few times (much less than half of the time)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">4</td>
                        <td>Sometimes (about half of the time)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">5</td>
                        <td>Most times (much more than half of the time)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">6</td>
                        <td>Almost always / always</td>
                      </tr>
                    </table></td>
                </tr>
                <tr valign="top"> 
                  <td height="20" colspan="5">&nbsp;</td>
                </tr>
                <tr valign="top"> 
                  <td><strong>3.</strong></td>
                  <td width="270"><strong>How many pads or adult diapers per 24-hour 
                    period did you use to control urine leakage during the last 
                    four (4) weeks?</strong><br> <br> <table width="270" border="0" cellspacing="0" cellpadding="0">
                      <tr valign="top"> 
                        <td width="30" height="20">1</td>
                        <td width="240">None (or no leakage)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">2</td>
                        <td>An occasional pad or protective material</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">3</td>
                        <td>One pad per 24-hour period</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">4</td>
                        <td>Two pads per 24-hour period</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">5</td>
                        <td>Three or more pads per 24-hour period</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">6</td>
                        <td>Adult diapers</td>
                      </tr>
                    </table></td>
                  <td>&nbsp;</td>
                  <td><strong>6.</strong></td>
                  <td width="270"><strong>During the last four (4) weeks, when 
                    you had erections with sexual stimulation, how often were 
                    your erections hard enough for penetration (entering your 
                    partner)?</strong><br> <br> <table width="270" border="0" cellspacing="0" cellpadding="0">
                      <tr valign="top"> 
                        <td width="30" height="20">1</td>
                        <td width="240">No sexual activity</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">2</td>
                        <td>Almost never / never</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">3</td>
                        <td>A few times (much less than half of the time)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">4</td>
                        <td>Sometimes (about half of the time)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">5</td>
                        <td>Most times (much more than half of the time)</td>
                      </tr>
                      <tr valign="top"> 
                        <td height="20">6</td>
                        <td>Almost always / always</td>
                      </tr>
                    </table></td>
                </tr>
                <tr valign="top"> 
                  <td height="20" colspan="5">&nbsp;</td>
                </tr>
                <tr align="center" valign="top"> 
                  <td height="30" colspan="5"> 
                    <table width="620" border="0" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
                      <tr> 
                        <td class="FormInnerRowBottomBorder"> <table width="610" border="0" cellpadding="8" cellspacing="0">
                            <tr> 
                              <td><span class="blackBoldText">Person completing 
                                this form:&nbsp;&nbsp;&nbsp;&nbsp;</span> <input name="fellow2225" type="checkbox" id="fellow2225">
                                Patient&nbsp;&nbsp; <input name="fellow22222" type="checkbox" id="fellow22222">
                                Family Member&nbsp;&nbsp; <input name="fellow22232" type="checkbox" id="fellow22232">
                                Friend&nbsp;&nbsp; <input name="fellow22242" type="checkbox" id="fellow22242">
                                Other</td>
                            </tr>
                            <tr> 
                              <td height="25" valign="bottom" class="blackBoldText"><span class="blackBoldText">Signature: 
                                _______________________________________________________________</span><br><br></td>
                            </tr>
                          </table>
                         </td>
                      </tr>
                      <tr> 
                        <td> 
							<table width="610" border="0" cellpadding="8" cellspacing="0">
                            <tr> 
                              <td><span class="blackBoldText"><br>
                                Reviewer:&nbsp;&nbsp;&nbsp;&nbsp;</span> <input name="fellow222" type="checkbox" id="fellow222">
                                Attending&nbsp;&nbsp; <input name="fellow2222" type="checkbox" id="fellow2222">
                                Fellow&nbsp;&nbsp; <input name="fellow2223" type="checkbox" id="fellow2223">
                                PA / NP&nbsp;&nbsp; <input name="fellow2224" type="checkbox" id="fellow2224">
                                RN </td>
                            </tr>
                            <tr> 
                              <td height="25" valign="bottom" class="blackBoldText"><span class="blackBoldText">Signature: 
                                _______________________________________________________________</span> 
                              </td>
                            </tr>
                          </table>
                         </td>
                      </tr>
                    </table>
                  </td>
                </tr>
              </table>
             </td>
            <td>&nbsp;</td>
          </tr>
          <tr valign="top"> 
            <td colspan="3">&nbsp;</td>
          </tr>
        </table>
       </td>
    </tr>
    <tr> 
      <td height="14" align="center" valign="bottom" class="blackBoldText">GU20<img src="../../Images/shim.gif" border="0" width="45" height="1">U24<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 6/04<img src="../../Images/shim.gif" border="0" width="45" height="1">rev:01/03/05<img src="../../Images/shim.gif" border="0" width="45" height="1">Page 
        1 of 1<img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">20</span></td>
    </tr>
  </table>
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