Patient Information
Step 1 of 9
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Location
Please Select
Tarzana
Irvine
Long Beach
Rancho Cucamonga
Encino
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Section 1: Primary Symptoms
Step 2 of 9
What symptoms are you experiencing?
Heavy menstrual bleeding
Pelvic pain
Pelvic pressure/fullness
Frequent urination
Constipation
Pain with intercourse
Abdominal bloating / enlargement
Fatigue
Other
Which symptom bothers you the most?
Bleeding
Pain
Pressure/bulk
Other
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Section 2: Menstrual Bleeding
Step 3 of 9
How long does your period typically last?
Less than 3 days
3-5 days
6-7 days
More than 7 days
How many days involve heavy bleeding?
0-1 days
2-3 days
4-5 days
More than 5 days
On heavy days, how often do you change protection?
Every 3-4 hours
Every 2-3 hours
Every 1-2 hours
More than once per hour
Do you pass blood clots?
No
Yes small
Yes large
Have you experienced any of these due to bleeding?
Iron deficiency
Iron infusions
Blood transfusion
None
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Section 3: Pain Assessment
Step 4 of 9
How would you rate your pelvic pain during your period?
0-3 Mild
4-6 Moderate
7-10 Severe
Do you have pelvic pain outside your period?
No
Occasionally
Frequently
Constant
Have you visited the ER for this pain?
No
Yes once
Yes multiple times
What do you use for pain management?
None
OTC (ibuprofen Tylenol)
Prescription medication
Other
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Section 4: Pressure Symptoms
Step 5 of 9
How often do you urinate during the day?
Normal (every 3-4 hours)
Every 2-3 hours
Every 1-2 hours
More often than every hour
Do you wake up at night to urinate?
No
1 time
2-3 times
4 or more times
Do you feel pelvic pressure or fullness?
No
Mild
Moderate
Severe
Is your abdomen enlarged or bloated?
No
Slightly
Moderately
Significantly
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Section 5: Prior Treatments
Step 6 of 9
Have you tried any treatments for fibroids?
Birth control pills
Hormonal IUD
Tranexamic acid
GnRH medications
Prior surgery myomectomy
No prior treatment
If you've tried treatments, did they help?
Yes
Somewhat
No
Do you want to preserve the option of pregnancy?
Yes
No
Unsure
Have you discussed surgical options?
Yes
No
Unsure
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Section 6: Medical History
Step 7 of 9
Do you have any of the following conditions?
High blood pressure
Diabetes
Heart disease
Sleep apnea
Obesity BMI over 35
Anemia
None of these
Have you ever had problems with anesthesia or sedation?
No
Yes
If yes, please describe anesthesia issues
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Section 7: Recovery Preferences
Step 8 of 9
How would you describe your pain tolerance?
High
Moderate
Low
After procedures, you typically:
Recover quickly with minimal pain
Need moderate pain control
Require strong pain medication
What would you prefer after your procedure?
Go home the same day
Stay for extended monitoring
Unsure
Do you have someone who can stay with you for 24 hours post-procedure?
Yes
No
How far do you live from the treatment center?
Less than 30 min
30-60 minutes
More than 1 hour
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Section 8: Goals and Your Story
Step 9 of 9
What is your main goal from treatment?
Stop heavy bleeding
Reduce pain
Reduce pressure or bulk
Avoid surgery
Improve overall quality of life
What concerns you most about treatment?
Tell us your story in your own words. How has this affected your daily life? What led you to seek treatment now?
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