Menu
Home
Our Doctors
Fibroids 101
What are Fibroids?
Fibroid Symptoms
Fibroid Treatment Options
Interventional Radiology
UFE/Advantages of UFE
Am I a Candidate for UFE?
Steps for Treatment
FAQ
+
UFE vs. Surgery
Blog
Resources
Contact Us
Submit Patient Forms Online
Download Patient Forms
Insurance Info
Patient Referrals
+
Home
Submit Patient Information
Submit Patient Information
Securely Submit Patient Information
Patient Information
Date
*
MM slash DD slash YYYY
Name
*
First
Middle
Last
D.O.B
*
Age
*
Referring Doctor
Reason For Visit
*
Symptoms
Do you experience any of the following?
*
Heavy Menstrual Bleeding
Painful Periods
Backache or Leg Pain
Period Lasting More Than A Week
Pelvic Pain or Pressure
Constipation
Frequent Urination
Difficulty Emptying Bladder
Enlarged Abdomen
Bloating
Pain During Intercourse
NONE
Other Symptoms Not Listed
Please check any methods you have used to help with your symptoms
Birth Control
IUD (intrauterine device)
Pain Medications
Other Methods Not Listed
Fibroid History
Is there a family history of fibroids?
*
Yes
No
Which family member?
Mother
Sister(s)
NONE
Bleeding History (Check all that apply)
Take an iron supplement for low blood count (anemia)
*
Yes
No
Required a blood transfusion for low blood count (anemia)
*
Yes
No
Average number of pads / tampons per day?
Average number of days in menstrual period?
Average number of days between menstrual periods?
Have you ever been prescribed or use the following medications?
*
Aspirin
Coumadin / warfarin
Eliquis
Xarelto
Pradaxa
Plavix
None
Have you received blood-thinning medications such as heparin or lovenox before or after a procedure?
*
Yes
No
Gynecology History
Number of pregnancies
*
Have you ever had a miscarriage?
*
Yes
No
Do you desire to become pregnant again in the future?
*
Yes
No
Date of last pap smear?
MM slash DD slash YYYY
Results of pap smear?
Have you ever been treated for a sexually transmitted disease (STD)?
*
Yes
No
Social History
Do you smoke?
*
Yes
No
Please tell us about your occupation? If retired, please tell us about your previous work.
Marital status
*
Married
Single
Divorced
Widowed
Medications (please list ALL medications, dose and reason)
Do you take antibiotics before dental or invasive procedures?
Yes
No
Do you have a communicable disease such as hepatitis or HIV?
Yes
No
Do you have a hole in your heart such as Patent Foramen Ovale (PFO) or Atrial Septal Defect (ASD)?
Yes
No
Medical History (Please list ALL past or present medical problems)
Past Surgical History (Please list ALL past surgeries and include year of procedure)
Review Of Systems (please check ALL that apply)
Constitution
Weight Loss
Weight Gain
Night Sweats
Fever
Skin
Change in size/color of moles
Rash
Bruising
Eyes
Decreased Vision
Double Vision
Blurred Vision
Glasses
ENMT
Pain Deafness
Discharge
Ringing in ears
Sinus Drainage
Nose Bleed
Hoarseness
Cardiac
Palpitations
Chest Pain
Shortness of Breath
Fatigue
Swelling in feet / legs
Respiratory
Cough
Production of sputum
Coughing of blood
Pain
Gastro
Painful Swallowing
Nausea
Vomiting
Vomit Blood
Indigestion
Diarrhea
Constipation
Tarry Spools
Yellow Jaundice
Bloody Stools
Change in BMs
Genito
Malodorous Vaginal Charge
Kidney / Bladder Disease
Decreased Urine Stream
Unable to urinate
Painful urination
Blood in urination
Musc/Skel
Weakness Trauma
Limited Motion
Bone / Joint Deformity
Neuro
Paralysis
Weakness
Seizure
Fainting
Headache
Migraine
Migraine with aura
Numbness / tingling in extremities
Head / trauma
Psych
Anxiety / Depression
Hallucinations
Endocrine
Change of appetite
Excessive thirst / urination
Goiter
Hematology
Swollen lymph nodes
Bleeding disorders
Immuno
Immune disorders
Immunosuppressant
Email
This field is for validation purposes and should be left unchanged.