Fibroid Assessment Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Primary Care Doctor or OBGYN
Have you ever been diagnosed with a uterine fibroid?
*
Yes
No
I have experienced the following symptoms:
Pain/Discomfort
Abdominal Fullness or Pressure
Heavy Bleeding
Painful Periods
Location of pain/discomfort
Pelvis
Lower Abdomen
Lower Back
My pain/discomfort is best described as:
Dull Aching
Cramping
Sharp pain
Burning
My period is generally:
Light
Normal
Heavy
Long
Do you experience blood clots:
Yes
No
Average number of days of cycle:
Average number of pads or tampons per day:
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Should be Empty: