• Take the Quiz and Find Out if Our Minimally Invasive Fibroid Procedure Can Help You

  • Format: (000) 000-0000.
  • Date of Birth **
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  • Listed below are symptoms experienced by women who have 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 3 months.

    There are no right or wrong answers. Please be sure to answer every question by checking(✓) the most appropriate box. If a question does not apply to you, please mark "not at all" as a response.

  • During the previous 3 months, how distressed were you by...

  • 1. Heavy bleeding during your menstrual period*
  • 2. Passing blood clots during your menstrual period*
  • 3. Fluctuation in the duration of your menstrual period compared to your previous cycle*
  • 4. Fluctuation in the length of your monthly cycle compared to your previous cycles*
  • 5. Feeling tightness or pressure in your pelvic area*
  • 6. Frequent urination during the daytime hours*
  • 7. Frequent nighttime urination*
  • 8. Feeling fatigued*
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