UTERINE FIBROID SYMPTOM & QUALITY OF LIFE QUESTIONNAIRE (UFS-QOL)

UTERINE FIBROID SYMPTOM & QUALITY OF LIFE QUESTIONNAIRE (UFS-QOL)

Listed below are symptoms experienced by women who have suspected uterine fibroids. Please consider each symptom as it relates to your uterine fibroids or menstrual cycle. Each question asks how much distress you have experienced from each symptom during the previous three months. Answering these questions will help your Doctor at iRWA screen & track your symptoms.
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
How much have you been bothered by heavy menstrual bleeding or passing clots?
How much have you been bothered by irregular, prolonged or unpredictable periods?
Have you been diagnosed or treated for low iron?
How much have you been bothered by pelvic pressure, bloating or abdominal fullness?
How much have you been bothered by frequent urination, including waking at night to pass urine?
How much has your menstrual symptoms affected your energy, physical activity, work or usual daily activities?
How much has your menstrual bleeding affected your emotional wellbeing, confidence, social life or sexual relationships?
If you were to spend the rest of your life with your menstrual bleeding and/or pelvic pressure the way they have been over the past 3 months, how would you feel about that?
There are multiple causes for the aforementioned symptoms, this questionnaire is designed to be used in the context of known or suspected fibroids
Date

DayMonthYear
Date
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