_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.

Have you experienced any of the following symptoms?

(Check all that apply)

Which of the following abnormal period symptoms have you experienced?

(Check all that apply)

Please tell us more about your abnormal periods.

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

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

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

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

How long have you had symptoms?

How significantly do your symptoms impact your life?

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

How many different physicians have you discussed your symptoms with?

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

(Check all that apply)

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?

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?*

Do you have Essure for sterilization?*

What is your age?*

First Name*

Last Name*

Phone

Email*

Zip Code*

Insurance Carrier*

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Physician Name

Name

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