Uterine Fibroid Questionnaire
Please answer each of the questions below.

More information about Uterine Fibroids:
https://www.sirweb.org/patient-center/uterine-fibroids/

First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Email Address
Your answer
1. Race
2. Date of Birth
MM
/
DD
/
YYYY
3. Height in Feet and Inches (example: 5'4")
4. Weight (Pounds)
Your answer
5. Do you experience heavy bleeding during your menstrual period?
6. Do you pass blood clots during your menstrual period?
7. Does the length of your menstrual cycle fluctuate?
8. Do you feel tightness, pressure or pain in your pelvic area?
9. Do you experience pain during sexual intercourse?
10. Do you have a frequent urge to urinate?
11. Do you often feel fatigued?
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