RRPF Medical Practitioner Survey

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To be completed by medical professionals treating patients with RRP.

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Doctors and Nurses, this survey is intended to provide a statistical overview of the RRP patient population that you are treating. We appreciate your taking the time to answer these questions.


 

 

Return email Address:   

Person submitting form:

Today's Date: (mm-dd-yy)

If this is the first time that you have completed an RRPF Practitioner survey, check here     

If this is an update for a medical practice already registered with the RRPF check here
(Only provide your name and that information you wish to update)

Names and Phone Numbers:

Doctor Name:  

Medical Practice Name:

Address Line 1:     

Address Line 2:     

City:        State:        Zip:

Phone:     (area code-number)

Fax Number: 

E-Mail Address:   

If this is a new address check here               

 

Surgical approach(s) used  (select all that apply) :

Office surgical approach:             

Other surgical approach:             

Patient population information:

Total number of RRP patients in your practice

Male patients   Female patients

Pediatric   Adult

 

RRP patient surgical frequency information:

Number of patients requiring surgery MORE frequently than every 2 months

Male    Female

 

Number of patients requiring surgery between 2 and 12 months

Male    Female

 

Number of patients requiring surgery LESS frequently than every year

Male    Female

Adjunct therapy treatment information:

Please indicate the number of patients being (or that have been) treated with the following:

Artemisinin   

Avastin   

Celebrex   

Cidofovir   

DIM   

I3C   

Interferon   

MMR/Mumps Vaccine   

PDT   chemical agent:   

Other   specify:   

 

Additional Comments:   

 

 

Thank you for taking the time to complete this survey.        

You may want to print out a hardcopy of this form as a backup for your records, before submitting        

Please confirm your submission by sending e-mail to bills@rrpf.org        

  


RRP Foundation.
Last revised:  June 19, 2013