JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Ezzy Access pants survey before use
Tell us how we can help you become more active with your disability
* Indicates required question
Name
*
Your answer
Email
*
Your answer
Address with City and State.
*
Your answer
Phone number
*
Your answer
Best time to call/text
*
Morning
Afternoon
Evening
Anytime
Other:
Required
What is the level of your Spinal Cord Injury or disability
*
Your answer
How often do you catheterize during the day?
*
3-4 times per day
4-6 times per day
6 or more times per day
Other:
Do you feel trapped by your current cathing regimen?
*
Yes
No
Other:
Have you gotten the Mitroffanoff surgery?
*
Yes
No
Were you offered different options from the Mitroffanoff procedure to help you catheterize?
*
Yes
No
Other:
How long does it take you to use the bathroom and catheterize?
*
5- 10 minutes
10 - 20 minutes
20 + minutes
Other:
Are you able to catheterize in public restrooms?
*
Yes
No
If you answered No what stops you from using public restrooms?
*
Your answer
How often do you catheterize in public restrooms?
*
Never
Sometimes
Always
Would you be interested in having someone help you learn to catheterize in public restrooms.
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
