Survivor 2 Survivor for Patients to Fill Out

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2. Contact Information

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Name:

 

 

   

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*3.
Question - Required - Are you a:





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*8.
Question - Required - Patient gender:


*9.


10.
Question - Not Required - Generally speaking, what would be the best times for an S2S call from the volunteer?

*11.

(Maximum response 255 chars, approx. 5 rows of text)

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*18.
Question - Required - What would the patient like to discuss with the S2S volunteer?
Please make at least 1 selection from the choices below.

19.
Question - Not Required - If you would like to talk about the bladder removal surgery (radical cystectomy): what urinary diversions are you considering? You may select more than one.

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   Please leave this field empty