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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