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Contact Us – Sonata Patient Support

Sonata Patient SUPPORT

Please complete this questionnaire to help our Sonata Nurse Advocates understand your specific concerns and evaluate your treatment options.

"*" indicates required fields

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.

Hidden

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?

1 – 6 months

6 months to 1 year

1-3 years

3-6 years

6+ years

How significantly do your symptoms impact your life?

Never

Rarely

Sometimes

Often

Always

Hidden

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

No frustrations

Very Mild

Mild

Moderate

High frustrations

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

Hidden

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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Comments

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Gynesonics, Inc. | 600 Chesapeake Drive | Redwood City, CA 94063

Copyright 2022 Gynesonics | WS 05195-001 Rev F

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