• Patient Information

    Complete your patient details and medical history so our specialists can guide your least invasive treatment options.
  • Uterine Fibroid Treatment Intake — West Medical
    Your answers help our specialists understand your situation and recommend the least invasive path to relief. All information is kept secure and confidential.
  • Date of Birth*
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  • Format: (000) 000-0000.
  • Family history of uterine fibroids in close family members (mother, sister)

  • Prior Treatments

  • Have you tried any of the following treatments for your fibroids? (Select all that apply)
  • If you've tried treatment, how did you respond?

  • Surgical History & Treatment Preferences

  • Have you had prior surgery for fibroids?*
  • Has a hysterectomy been recommended to you?*
  • Would you prefer to avoid a hysterectomy if possible?

  • Reproductive Goals

  • Do you want to preserve the option of future pregnancy?*

  • Anesthesia History

  • Have you ever had a reaction or problem with anesthesia or sedation?*

  • Bleeding Pattern

  • How would you describe your menstrual bleeding pattern?*
  • On your heaviest days, what kind of protection do you need? (Select all that apply)
  • How much protection do you use per day?
  • Do you pass blood clots?*
  • Is your bleeding affecting your daily life?*

  • Anemia & Energy Levels

  • Have you been diagnosed with anemia (low blood count) related to your bleeding?*
  • If yes, have you experienced any of the following? (Select all that apply)
  • Have you received treatment for anemia?

  • Pain Assessment

  •
  • When do you experience this pain?*
  • How does this pain affect your daily activities?*
  • How do you currently manage this pain? (Select all that apply)
  • Have you ever experienced unusually severe pain after a medical procedure?

  • Access to Care & Treatment History

  • Have you seen a doctor for this condition before?*
  • What treatment options have you been offered or discussed with a provider? (Select all that apply)
  • How long did you have to wait to be seen or treated?

  • Pressure & Bulk Symptoms

  • Fibroids can press on nearby organs in ways that are easy to dismiss but important to treat.
  • How often do you urinate during the day?*
  • Do you wake up at night to urinate?*
  • Do you feel pelvic pressure or fullness?*
  • Is your abdomen enlarged or bloated?*
  • Have you experienced any disruption in your care? (Select all that apply)
  • Do you feel your condition is getting worse while you wait for treatment?*
  • Have you had a pelvic ultrasound, MRI, or CT scan to evaluate your fibroids or symptoms?*
  • When was the imaging done?
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  • Your Symptoms

  • What symptoms are you experiencing? (Select all that apply)*
  • Which symptom bothers you the most?*

  • Ruling Out Other Conditions

  • Do you experience any of the following? (Select all that apply)
  • Do you ever leak urine?
  • Do any of the following apply to you? (Select all that apply)*

  • Comfort & Recovery Preferences

  • How would you describe your pain tolerance?*
  • After medical procedures, how do you typically recover?*
  • Are you concerned about pain after your procedure?
  • What would you prefer after your procedure?*

  • Support at Home

  • Do you live alone?
  • Do you have someone who can stay with you for the first 24 hours after your procedure?*

  • Impact on Daily Life

  • How has this condition affected your ability to work?
  • How has it affected your daily activities overall?
  • How has it affected your relationships or intimacy?

  • Your Goals & Your Story

  • What is your main goal for treatment?*
  • How urgently do you feel you need treatment?*
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