Contact
Information
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| Full
Name: |
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| Email
Address: |
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| Street
Address: |
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| City: |
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| State
/ Province: |
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| Postal
Code (Zip): |
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| Country: |
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| Home
Phone with area code: |
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| Work
Phone with area code: |
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| Fax
Number with area code: |
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Clinical
Information
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| Date
Of Birth (Month/Day/Year): |
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| Height: |
Weight: |
| Sex: |
Male
Female |
| Marital
Status: |
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| Number
of Pregnancies: |
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| Number
of Deliveries: |
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| Number
of Miscarriages |
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| Have
you had any previous surgery on the
Female Reproductive system? |
Yes.
Please Describe:
No |
| Are
you having difficulties in getting
pregnant? (only if applicable to you) |
Yes
No
Don't Know |
| Are
you still interested in having
children? |
Yes
No
Not Sure |
| Do
you currently take any hormones? |
Estrogen
Progesterone |
| Are
you in Menopause? |
Yes
No |
| Which
medical conditions do you suffer
from? Please choose all that apply. |
Fibroids
Endometriosis
Pelvic
Relaxation
Endometrial Hyperplasia
Other:
Please Describe:
Not Sure |
| Describe
your problem(s) with fibroids, be
specific about symptoms: |
Pelvic
Pressure
Excessive / Heavy
Bleeding
Painful
Periods
Painful Intercourse
Reduced Bladder Capacity
Constipation
Changing
Waste
Recurrent Pregnancy Loss
Infertility |
| Describe
size, number and location of fibroids
- were you treated for fibroids in
the past, if yes, how? |
|
| List
previous abdominal surgeries: |
|
| Do
you wish to preserve your fertility? |
Yes
No |
| Did
you ever have a pap smear indicating
precancerous cells? |
Yes
No |
| Indicate
your gynecologists treatment
suggestion. |
|
| Indicate
reason(s) for contacting us: |
I
would like to do everything possible
to keep my uterus
I just don't seem to get
the answers I'm looking for
I
have heard about laparoscopy and wish
to avoid open surgery so I can be
discharged from the hospital on the
same day
I just don't want a
hysterectomy and am willing to see a
specialist that can preserve my
uterus
My doctor tells me I have
adenomyosis and that is the reason I
have to have a hysterectomy
I feel that I should have
the procedure that is best for me
personally
I
am prepared to travel
I am prepared to cover
expenses of up to $5,000 to get
proper care
I am prepared to cover
expenses over $5,000 to get proper
care |
Other
Information
|
| Profession: |
|
| Please
state how this condition affects your
life on a professional / personal
basis: |
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Location
|
| What
is your preferred surgery location? |
|
Health
Insurance and Financing: USA
Residents Only
|
| Type
of Health Insurance? |
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| Name
of Health Insurance Company: |
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| Will
you need financing for your
procedure? |
Yes
No
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| How
did you find out about us? |
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Your
submitted information will be handled
with complete confidentiality.
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