Dallas Fibroids - UFE Risk Assessment

Uterine Fibroid Symptom And Health-Related Quality Of Life Questionnaire
First Name **
Last Name **
Email **
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Preferred Location **
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MonthDayYear
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*

Not at allA little bitSome-whatA great dealA very great deal
2. Passing blood clots during your menstrual period*

Not at allA little bitSome-whatA great dealA very great deal
3. Fluctuation in the duration of your menstrual period compared to your previous cycle*

Not at allA little bitSome-whatA great dealA very great deal
4. Fluctuation in the length of your monthly cycle compared to your previous cycles*

Not at allA little bitSome-whatA great dealA very great deal
5. Feeling tightness or pressure in your pelvic area*

Not at allA little bitSome-whatA great dealA very great deal
6. Frequent urination during the daytime hours*

Not at allA little bitSome-whatA great dealA very great deal
7. Frequent nighttime urination*

Not at allA little bitSome-whatA great dealA very great deal
8. Feeling fatigued*

Not at allA little bitSome-whatA great dealA very great deal
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Total Score
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