Online Patient Questionnaire

We appreciate your participation in our questionnaire. The best possible way for us to improve our services is to hear from you, the people we are here to serve.

Many people have fixable problems that they endure instead of treat, especially women with leaking problems and men with erectile dysfunction. These conditions are both prevalent and underreported. Your success story may be an invaluable aid and inspiration to someone else who is suffering with the same condition and is wondering if he or she should seek treatment. You can play a part in ending someone’s suffering simply by telling your story.

Your responses are private and confidential. Please feel free to answer anonymously if you’d like. Thank you for your feedback, it’s invaluable to us.

Please only respond to the questions that seem relevant to you.

First name:
Last name:
Street address:
City:
State:
Zip code:
Telephone:
E-mail:
Type of Treatment:	Surgery (Please Specify):   Non-Surgery Related Treatment (Please Specify):   Doctor's Visit Because of a Problem:   Regular Check-Up:
Overall Experience:	Outstanding  Satisfactory  Dissatisfactory Comments:
Experience with Doctor(s):	Outstanding  Satisfactory  Dissatisfactory Comments:
Experience with Administrative Staff:	Outstanding  Satisfactory  Dissatisfactory Comments:
Dr. Muench has a reputation for excellence. Was that confirmed by your experience with him? (The space in the box is unlimited. We appreciate your detailed response).
Was Dr. Muench referred to you by someone who was pleased with the treatment they had had?
Has your treatment made a big difference in your quality of life?
Was it impactful enough to change your life?
If so, could you please give an example of how treatment has changed your life? For example, in cases of corrected incontinence many people say how nice it is to be able to go out in public without pads, confident they wont have an embarrassing leak. (The space in the boxes is unlimited. We appreciate your detailed response).
What was the best part of your experience? (The space in the boxes is unlimited. We appreciate your detailed response).
In which areas, if any, do you think we could improve?
Was your doctor’s skill-level high?
Were you pleased with the outcome of your treatment/surgery?
Was your recovery better than you expected?
If you had to go through the same procedure again, would you choose the same doctor?
Is there anything we could have done that would have made your visit/procedure more comfortable?
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