Fibroid Study

Demographic Questions

Age:

Please complete this field.

How long have you known about your fibroids

Please complete this field.

Problems

Have you Had Heavy Bleeding?

Please select an option.

Have you Had Prolonged Bleeding?

Please select an option.

Have you Had Bleeding Between Periods?

Please select an option.

Have you Had Worse Cramps

Please select an option.

Have you Had Pain with Intercourse?

Please select an option.

Have you Had Pain Between Periods?

Please select an option.

Has Surgery Already Been Advised?

Please select an option.

Has Surgery Already Been Scheduled?

Please select an option.

Contact Information

First Name

Please complete this field.

Last Name

Please complete this field.

Phone

Please complete this field.

Upload Ultrasound / Other Imaging Reports

Click to upload files

Subscribe to updates from Advanced Women's Health Institute