Get Uterine Fibroid Patient Questionnaire -

Filling out the Uterine Fibroid Patient Questionnaire is an essential step in assessing your health and determining the appropriate care. This guide will provide clear instructions on each section of the form, ensuring a smooth and efficient online experience.

Follow the steps to successfully complete the questionnaire.

1. Click the ‘Get Form’ button to obtain the questionnaire and open it in your document editor.
2. Begin by entering your name and UCLA ID number at the top of the form. It is essential to provide accurate identification details to ensure proper record management.
3. Move to the first section regarding your last menstrual period. Indicate the frequency and duration of your menstrual cycles, and provide information on when fibroids were diagnosed, how the diagnosis was made, and the date of your last Ob/Gyn exam.
4. In the symptoms section, circle the symptoms you are currently experiencing. If applicable, provide details regarding pain, pressure, or bleeding, along with the severity of pain on a scale from 1 to 10.
5. Next, describe any tests you have undergone related to fibroids, including the dates and findings of past examinations such as PAP smears, ultrasounds, and pelvic exams.
6. List any allergies you may have, including medications, food, or other substances. Complete the medications section by detailing any medications you are currently taking, especially those used for controlling bleeding or shrinking fibroids.
7. Provide details regarding your OB/GYN and indicate if you are interested in being referred to an UCLA OB/GYN. Fill out the family planning section by noting any intentions to conceive and current contraceptive usage.
8. Document any additional medical conditions you may have, and if applicable, indicate your family history of fibroids.
9. In the insurance section, specify your insurance provider, policy number, and contact information for your insurance company.
10. Complete the patient data section with your contact details, including phone numbers and address. Provide emergency contact information and any relevant data regarding past medical records.
11. Once you have reviewed all the information for accuracy, save the completed form, and choose the option to download, print, or share it as needed.

Start filling out the Uterine Fibroid Patient Questionnaire online to facilitate your healthcare journey.