Primary information Name ………………………………………………………………………………….. Age / Gender ………………………………….. Address : City / State ......................................................... ................................................................... ... Mobile Number …………………………………………………………………………………….. Email Address …………………………………………………………………………………… Date of Spinal cord injury / disease .................................. ............ Level of spinal cord injury ..................................... ...................... Hand function : Yes / OK ............ Not adequate for CIC ............... Current method of bladder management : ………………………………………………………………………… ...