Do you agree to participate in this study?
* must provide value
Yes, I am willing to participate in this study. (Go to question 1)
No, I do not want to participate in this study. (Please return the survey to us by mail in the envelope provided.)
1. What is your date of birth?
* must provide value
Today D-M-Y
2. What is your gender?
* must provide value
Male
Female
3. Are you of Latino or Hispanic origin?
No
Yes
4. What race do you consider yourself to be? Choose one or more of the following.
5. What is the highest grade or year of school you completed?
GED or high school graduate
Some college
Bachelor's/college degree
Post-graduate degree
6. Which of the following best describes your CURRENT service in the United States military?
Active Duty
National Guard or reserve
Retired from military service
Discharged from military (non-medical)
On the temporary disability retired list (TDRL)
On the permanent disability retired list (PDRL)
Medically discharged from military service
On medical hold
a. Is your disability, medical discharge or medical hold primarily related to your GU injury or some other health condition?
GU Injury
Other health condition
7. Select your highest pay grade while on active duty.
E-1
E-2
E-3
E-4
E-5
E-6
E-7
E-8
E-9
W-1
W-2
W-3
W-4
W-5
O-1
O-1E
O-2
O-2E
O-3
O-3E
O-4
O-5
O-6
O-7
O-8
O-9
O-10
O-11
8. In which branch of the military did you serve at the time of your GU injury?
Army
Navy
Marines
Air Force
Coast Guard
National Guard/Reserves
9. What is your current marital status?
Married
Living with a partner
Separated
Divorced
Widowed
Never Married
a. If you are currently married, are you living with your spouse?
No
Yes
10. At the time of your GU injury, what was your marital status?
Married
Living with a partner
Separated
Divorced
Widowed
Never Married
11. How many people currently live in your household?
12. During the past 6 months, which of the following describes what you are doing? (Select all that apply)
a. Please specify the "Other" reason for what you were doing the past 6 months?
13. During the past week, about how many hours did you work for pay?
14. In the LAST YEAR, about how much income did you personally earn (include salary, wages, income from social security, VA benefits, or income from any other source)?
< $25,000
$25,000-$64,999
$65,000-$99,999
$100,000-$159,999
$160,000 and higher
15. Do you currently have any form of health insurance that pays for all or part of your medical care?
No
Yes
a. What type of insurance(s) do you currently have? (Select all that apply)
b. Please specify the "Other" insurance you currently have?
16. Since your GU injury, how many times were you admitted as a patient to a hospital?
0
1
2
3
4
5
6
7
8
9
10+
16a. How many of these admissions were for problems related to your GU injury?
17. What was/were the reason(s) for your hospitalization(s)? (Select all that apply)
18. Since your GU injury, have you been diagnosed by a health care provider with a mental health condition?
Yes
No
I don't know
19. Do you believe your mental health condition was associated or influenced by your GU injury?
Yes
No
I don't know
20. If you did not receive help for mental or emotional problems but needed them, which of the following reasons prevented you from obtaining help? (Select all that apply)
a. You selected "Other" for reason that prevented you from receiving mental health support. Please specify that reason.
21. Where did you receive help for a mental or emotional problem? (Select all that apply)
a. Please specify "Other" for where you received help for a mental or emotional problem?
22. Approximately how many visits did you make in the past 12 months for mental health services?
None
Once
2 times
3 times
4 times
5 or more times
23. During the past 12 months, did you receive help for mental or emotional problems, including depression?
Yes
No
24. During the past 12 months, did you receive help for a urinary condition?
Yes
No
25. Do you believe your urinary condition was associated or influenced by your GU injury?
Yes
No
26. Has a health care provider diagnosed you with a urinary condition?
Yes
No
I don't know
27. If you did not receive help for urinary problems but needed them, which of the following reasons prevented you from obtaining help? (Select all that apply)
a. Please specify the "Other" reason you did not seek help with urinary problems.
28. Where did you receive help for a urinary problem? (Select all that apply)
a. Please specify where you received help for a urinary problem?
29. Approximately how many visits did you make In the past 12 months for health services associated with urinary problems?
None
Once
2 times
3 times
4 times
5 or more times
30. Since your GU injury, have you tried to conceive?
Yes
No
31. Since your GU injury, have you experienced fertility problems?
Yes
No
32. Do you believe your fertility problems are associated or influenced by your GU injury?
No
Yes
I don't know
33. Have you received medical treatment or other help (ex., adoption) for a fertility condition?
Yes
No
34. If you did not receive help for fertility problems but needed them, which of the following reasons prevented you from obtaining help? (Select all that apply)
a. Please specify the "other" reason you did not seek help for fertility problems.
35. During the past 12 months, did you receive help for a condition associated with sexual functioning?
Yes
No
36. Has a health care provider diagnosed you with a condition associated with sexual functioning?
No
Yes
I don't know
37. Do you believe your sexual functioning was associated or influenced by your GU injury?
No
Yes
I don't know
38. Have you received mental health services to address your sexual functioning?
Yes
No
39. Where did you receive mental health services for sexual problems? (Select all that apply)
a. Please specify the "Other" reason for where you received mental health services for sexual problems?
40. Approximately how many visits did you make to a counselor/therapist for sexual problems in the past 12 months?
None
Once
2 times
3 times
4 times
5 or more times
41. If you did not receive help for problems associated with sexual functioning but needed them, which of the following reasons prevented you from obtaining help? (Select all that apply)
a. Please specify the "other" reason you did not seek help for sexual function.
42. Before your GU injury, did you have any problems urinating (going pee)?
Yes
No
a. What problems did you have?
43. Before your GU injury, did you have any sexual problems?
Yes
No
a. What sexual problems did you have before your GU injury?
44. Before your GU injury, were you told by a doctor that you were infertile?
Yes
No
46. Over the past 4 weeks, how many times did you typically get up at night to urinate?
None Once 2 times 3 times 4 times 5 or more times
47. If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?
Delighted
Pleased
Mostly satisfied
Equally Satisfied and Dissatisfied
Mostly dissatisfied
Unhappy
Terrible
49. Over the past 4 weeks, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
No sexual activity
Extremely Difficult
Very Difficult
Difficult
Slightly Difficult
Not Difficult
50. Over the past 4 weeks, how many times have you attempted sexual intercourse?
No attempts
1-2 attempts
3-4 attempts
5-6 attempts
7-10 attempts
11+ attempts
51. Over the past 4 weeks, how much have you enjoyed sexual intercourse?
No intercourse
No enjoyment at all
Not very enjoyable
Fairly enjoyable
Highly enjoyable
Very highly enjoyable
52. Over the past 4 weeks, how often have you felt sexual desire?
Almost never or never
Less than half the time
Half the time
More than half the time
Almost always or always
53. Over the past 4 weeks, how would you rate your level of sexual desire?
Very low or none at all
Low
Moderate
High
Very high
54. Over the past 4 weeks, how do you rate your confidence that you can get and keep your erection?
Very low or none at all
Low
Moderate
High
Very high
56. Do you have a decrease in libido (sex drive)?
Yes
No
57. Do you have a lack of energy?
Yes
No
58. Do you have a decrease in strength or endurance?
Yes
No
59. Have you lost height?
Yes
No
60. Have you noticed a decreased "enjoyment of life?"
Yes
No
61. Are you sad and/or grumpy?
Yes
No
62. Are your erections less strong?
Yes
No
63. Have you noticed a recent deterioration in your ability to play sports?
Yes
No
64. Are you falling asleep after dinner?
Yes
No
65. Has there been a recent deterioration in your work performance?
Yes
No
66. Are you experiencing any pain related to your GU injury?
Yes
No
67. During the PAST 2 WEEKS, my appetite was poor.
No days or less than one day
1-2 days
3-4 days
5-7 days
Nearly every day for 2 weeks
Every day for 2 weeks
68. In the PAST 4 WEEKS, on average, how intense was your pain?
0
1
2
3
4
5
6
7
8
9
10
69. During the PAST 2 WEEKS, I could not shake off the blues.
No days or less than one day
1-2 days
3-4 days
5-7 days
Nearly every day for 2 weeks
Every day for 2 weeks
70. About how many days in the PAST 4 WEEKS have you been kept from your usual activities such as work, school or housework because of your GU-associated pain?
0-2 days
3-5 days
6-8 days
9+ days
71. During the PAST 2 WEEKS, I had trouble keeping my mind on what I was doing.
No days or less than one day
1-2 days
3-4 days
5-7 days
Nearly every day for 2 weeks
Every day for 2 weeks
72. For how long have you experienced GU-associated pain?
< 4 Weeks
< 6 Months
6-24 Months
>2 Years
77. Are you limited in the amount of work you are able to do or in the kind of work you are able to do because of your health or problems related to your GU injury?
No, not limited at all
Limited in the amount of work
Limited in the kind of work
Limited in both the amount and kind of work
78. Are you limited in the amount of housework you are able to do or in the kind of housework you are able to do because of your health or problems related to your GU injury?
No, not limited at all
Limited in the amount of work
Limited in the kind of work
Limited in both the amount and kind of work
79. DURING THE PAST 7 DAYS, how many HOURS did you miss from work because of problems related to your health, including problems with your GU injury? Include hours you missed for sick days, times you went in late, left early, etc.
81. Does your health, including problems related to your GU injury, prevent you from being able to work at all outside the home?
Yes
No
a. Is it your GU injury that prevents you from working or some other health condition?
GU Injury
Other health condition
82. After your GU injury, were you able to return to the same duties you were doing before the GU injury?
Yes
No
83. Does your health, including problems related to your GU injury, interfere with your ability to do the same duties you did before your GU injury?
Yes
No
84. Does your health, including problems related to your GU injury, interfere with your ability to do your current job?
Yes
No
Not Applicable
85. Are you limited in school attendance because of your health, including problems related to your GU injury?
Yes
No
Not Applicable
86. Does your health, including problems related to your GU injury, limit your ability to take care of your home and family as well as you could before your GU injury?
Yes
No
100. In general how would you rate your health?
Excellent
Very Good
Good
Fair
Poor
104. During the past 4 weeks, how much did pain interfere with you normal work (including both work outside the home and housework)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
106. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
109. During the COVID-19, my household income has
Decreased
Increased
Not Changed
112. Are you willing to participate in additional research related to this project?
Yes
No
The researchers conducting this study would like to access your medical record to better understand genitourinary (GU) injury and describe the treatment received. If you give permission, the information that will be viewed in your medical record will be limited to the following:
Yes
No
On behalf of our entire team, thank you for taking the time out of your day to participate in our Trauma Outcomes and UroGenital Health in OEF/OIF (TOUGH) survey. We appreciate your help and contribution to this important research. Your feedback will directly help us ensure that wounded warriors are receiving the care required for their injuries. The information will be used to guide policies to ensure programs are in place to better serve service members with GU injuries.
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