_gravity_form_modal - Sonata Treatment

Contact a Nurse Advocate

Please complete this questionnaire to help our nurse advocates understand your specific concerns and evaluate your options.

First Name*

Last Name*

Phone*

Email*

Zip Code*

Insurance Carrier*

What is your age?*

Have you experienced any of the following symptoms?

(Check all that apply)

Abnormal periods
Pelvic Pressure
Pain
Excessive bloating of fullness even between periods
Urinary issues such as increased frequency or retention
Painful intercourse
None of the above

Which of the following abnormal period symptoms have you experienced?

(Check all that apply)

Heavy periods that interfere with daily activities or work
Periods that last longer than 7 days
Other abnormal periods

Please tell us more about your abnormal periods.

Please answer in your own words, skip if you don't feel comfortable sharing.

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On your heaviest days, how often do you need to change your pads or tampons?

More than once every 2 hours
Every 2-3 hours
Every 3 hours or less often

Hidden

Has a healthcare provider ever told you or a family member that you have an enlarged uterus or fibroids?

Yes
No
No formal diagnosis but I think I have fibroids
Not me but a friend or family member has

Hidden

Please answer the rest of the questions as if you are the person who has been told they have an enlarged uterus or fibroids.*

Ok, got it.

How long have you had symptoms?

How significantly do your symptoms impact your life?

Hidden

How would you rate your level of frustration with your symptoms?

Hidden

How many different physicians have you discussed your symptoms with?

1
2
3
4 or more

Has a physician suggested any of the following procedures/treatments as a treatment for you?

(Check all that apply)

Hysterectomy
Myomectomy
Uterine Artery Embolization
Medication Therapy (birth control pills or other medication)
Another Therapy
I don't recall

What other therapy has been recommended to you?

Please answer in your own words. Skip if you don’t feel comfortable answering or if you don’t remember.

What is your primary reason for seeking more information about Sonata?

Want to learn about all options
Want to discuss with my physician
Want to find a physician that offers Sonata
Another reason

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What is the other reason why you are seeking more information about Sonata?

Please answer in your own words. Skip if you don’t feel comfortable answering.

Are you currently pregnant?*

Yes
No

Hidden

Do you have Essure for sterilization?*

Yes
No
I don't know

Opt-In*

I am voluntarily providing the information requested in this survey, including my personal and health information. I understand that Gynesonics will use my personal and health information to help me identify a physician who may be able to treat my medical condition. I understand that once I provide such information it will be shared with Gynesonics representatives and physician offices and may be used to contact me for follow up communications including via phone, email or text messages.

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Physician Name

Name

This field is for validation purposes and should be left unchanged.