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Fibroid Study

Demographic Questions

Age:

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How long have you known about your fibroids

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Problems

Have you Had Heavy Bleeding?

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Have you Had Prolonged Bleeding?

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Have you Had Bleeding Between Periods?

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Have you Had Worse Cramps

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Have you Had Pain with Intercourse?

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Have you Had Pain Between Periods?

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Has Surgery Already Been Advised?

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Has Surgery Already Been Scheduled?

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Contact Information

First Name

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Last Name

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Email

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Phone

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Upload Ultrasound / Other Imaging Reports

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