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Fibroid Symptom Questionnaire

Fibroid Symptom Questionnaire

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Healthcare Provider's Name(Required)

First Last

Patient Name(Required)

First Last

Patient Date of Birth (MM/DD/YYYY)(Required)

Medical History

Date fibroids diagnosed (MM/YYYY)

Diagnosis Method

Check all that apply

Ultrasound

MRI

Physical Exam

Menstrual Cycle

Time between periods

<24 days (Frequent)

24-38 days (Normal)

>38 days (Infrequent)

Duration of period

1-4 days

5-8 days

8+ days

Bleeding volume

Light

Moderate

Heavy

During your heaviest day of bleeding, how many pads or tampons do you use?

1-5

6-10

11 or more

Do you pass blood clots during your period?

Yes

No

Have you ever been diagnosed with anemia?

Yes

No

Have you required a blood transfusion?

Yes

No

Symptoms

Check all that apply:

Painful intercourse

Heavy menstrual bleeding

Menstrual cramping

Frequent urination

Pelvic pressure

Interrupted sleep

Increased waist size

Constipation

Backache

Fatigue

Additional:

Additional symptoms

0 of 100 max characters

How long have you experienced these symptoms?

0 of 125 max characters

Medical Therapy to Date

Check all that apply:

Birth control pills

Lupron/Orilissa/Oriahnn

Medicated IUD (Mirena)/Progestins (including Depo-Provera)

Other

Other therapies

0 of 125 max characters

Lifestyle Adjustments

Do you experience psychological effects from your symptoms?

Low self-esteem

Depression

Anxiety

Lack of confidence

Other

Other

0 of 125 max characters

Do you miss days of work?

Yes

No

Average # of days of work missed per month

1-2 day

3-5 days

5+ days

Do you have issues soiling your clothes?

Yes

No

Do you avoid leaving home, or traveling, or attending social gatherings?

Yes

No

Do you have relationship stress due to your fibroid symptoms?

Yes

No

Would you be interested in an incisionless procedure to treat your fibroids?

Yes

No

Is there anything else you would like to share?

0 of 300 max characters

Email

If you would like a PDF copy for your records, please provide your email address.

ML 06269-001.B

Name

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