TURP Video Patient Feedback Form

1. How old are you?

2. Are you able to use the following devices? (check all that apply)

The internet via a computer
A smart phone
A tablet device
None of the above

3. Were you shown a video as part of the consenting process?

Yes
No

4. What procedure did you have done?

5. How was this done?

Cystoscopically (telescope via your water pipe into the bladder)
Laparascopically (key hole surgery through the abdomen)
Open Surgery
Robotic Surgery
Don't know / Not sure
Other (please specify):

6. Why did we undertake this procedure?

7. What are the main risks involved with the procedure?

8. On a scale from 1 to 5, please answer the following questions

	Extremely effective	Very effective	Moderately effective	Slightly effective	Not at all effective
How well did the video explain how the procedure is performed?	How well did the video explain how the procedure is performed? Extremely effective	How well did the video explain how the procedure is performed? Very effective	How well did the video explain how the procedure is performed? Moderately effective	How well did the video explain how the procedure is performed? Slightly effective	How well did the video explain how the procedure is performed? Not at all effective
How well did the video explain why it is performed?	How well did the video explain why it is performed? Extremely effective	How well did the video explain why it is performed? Very effective	How well did the video explain why it is performed? Moderately effective	How well did the video explain why it is performed? Slightly effective	How well did the video explain why it is performed? Not at all effective
How well did the video explain the risks and benefits of the procedure?	How well did the video explain the risks and benefits of the procedure? Extremely effective	How well did the video explain the risks and benefits of the procedure? Very effective	How well did the video explain the risks and benefits of the procedure? Moderately effective	How well did the video explain the risks and benefits of the procedure? Slightly effective	How well did the video explain the risks and benefits of the procedure? Not at all effective
How well did the video explain alternatives to the procedure?	How well did the video explain alternatives to the procedure? Extremely effective	How well did the video explain alternatives to the procedure? Very effective	How well did the video explain alternatives to the procedure? Moderately effective	How well did the video explain alternatives to the procedure? Slightly effective	How well did the video explain alternatives to the procedure? Not at all effective
How well did the video explain the recovery process after the procedure?	How well did the video explain the recovery process after the procedure? Extremely effective	How well did the video explain the recovery process after the procedure? Very effective	How well did the video explain the recovery process after the procedure? Moderately effective	How well did the video explain the recovery process after the procedure? Slightly effective	How well did the video explain the recovery process after the procedure? Not at all effective

9. How satisfied were you with the consenting process?

10. Are there any improvements you would recommend to the pre-operative consenting process?

11. Do you have any additional comments?

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