Phalloplasty Patient Satisfaction Survey

Aesthetic Plastic Surgery International
4216 King Street
King Street West Office Park
Alexandria, Virginia 22302

703•845•7400

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Phalloplasty Patient Satisfaction Survey
(Mailed 2001-2002)

STEPHEN X. GIUNTA, M.D., F.A.C.S.
4600 King Street, Suite 5D
Alexandria, Virginia 22302
(703) 845-7400

Dear _________:

We are asking you for your input in evaluating the outcome of your surgery. We thank you sincerely for your help and cooperation in this very important survey.

Please Check One:

Are your results satisfactory?

	Length	Thickness
Fully	__________	__________
Only in part	__________	__________
Not at all	__________	__________

Has your ability to get an erection:

Improved	__________
Decreased	__________
Remained the same	__________

Has your penile sensation:

Improved	__________
Decreased	__________
Remained the same	__________

Has your angle of erection gotten:

Better	__________
Worse	__________
Remained the same	__________

Would you do it over again?

Yes	__________
No	__________

Would you say you suffered any undo pain or complications? Please list if Yes.

Yes	__________
No	__________

Would you recommend this procedure to someone else?

Yes	__________
No	__________

Additional Comments:

Signature __________________

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