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Bill of Rights
Centers
Miami
Madrid
London
Physicians
Fernando J. Bianco, MD
Mark Emberton, MD
Edward L. Gheiler
Juan I. Martinez-Salamanca, MD
Ariel M. Kaufman, MD
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
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Contact Us
Urological Research Network
URN
home
Bill of Rights
Centers
Miami
Madrid
London
Physicians
Fernando J. Bianco, MD
Mark Emberton, MD
Edward L. Gheiler
Juan I. Martinez-Salamanca, MD
Ariel M. Kaufman, MD
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Clinical Trials
Contact Us
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Español
Rosenberg's Self-Esteem Scale
Survey Date
*
MM
DD
YYYY
Center
*
Perito Urology
CIPSSV
Urology Specialists
Lyx Miami
Lyx Spain
Lyx Mexico
Name
*
First Name
Last Name
DOB
*
Date of Birth
MM
DD
YYYY
Email
*
1- I feel that I am a person of worth, at least on an equal plane with others
*
0- Strongly Disagree 1- Disagree 2- Agree 3- Strongly Agree
0
1
2
3
2- I feel that I have a number of good qualities
*
0- Strongly Disagree 1- Disagree 2- Agree 3- Strongly Agree
0
1
2
3
3- All in all, I am inclined to feel that I am a failure
*
0- Strongly Agree 1- Agree 2- Disagree 3- Strongly Disagree
0
1
2
3
4- I am able to do things as well as most other people
*
0- Strongly Disagree 1- Disagree 2- Agree 3- Strongly Agree
0
1
2
3
5- I feel I do not have much to be proud of
*
0- Strongly Agree 1- Agree 2- Disagree 3- Strongly Disagree
0
1
2
3
6- I take a positive attitude toward myself
*
0- Strongly Disagree 1- Disagree 2- Agree 3- Strongly Agree
0
1
2
3
7- On the whole, I am satisfied with myself.
*
0- Strongly Disagree 1- Disagree 2- Agree 3- Strongly Agree
0
1
2
3
8- I wish I could have more respect for myself
*
0- Strongly Agree 1- Agree 2- Disagree 3- Strongly Disagree
0
1
2
3
9- I certainly feel useless at times
*
0- Strongly Agree 1- Agree 2- Disagree 3- Strongly Disagree
0
1
2
3
10- At times I think I am no good at all
*
0- Strongly Agree 1- Agree 2- Disagree 3- Strongly Disagree
0
1
2
3
Thank you!