Üst Bar Danışma formu

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UFE CONSULTATION FORM

Please answer the questions below and send the form so that we could evaluate whether or not you are a good candidate for the uterine fibroid embolization (UFE).

UFE Consultation Form

Your name and surname: *

How old are you?

Where do you live?

Your e-mail address:

Are you in the menapause?

If you have vaginal bleeding, please indicate the type. You can tick more than one.

Increased mensturation
Prolonged mensturation
Bleeding between mensturation
I do not have any abnormal bleeding

How were your fibroids diagnosed? You can tick more than one.

Gynecologic examination
Ultrasound
MRI

What are the number and size of the fibroids on ultrasound or MRI?

Did you have any treatment against your fibroids? You can tick more than one.

Oral contraceptive pills
Temporary menapause injections (Lucrin, Zoladex etc)
Myomectomy
I did not have any treatment

Did you have any abdominal surgery or radiotherapy?

Do you have any intrauterine contraceptive device?

Did you have a genital infection, or symtoms such as fever and genital discharge?

Do your mother or sister have uterine fibroids?

Do your mother or sister have any cancer of the breast, uterus or ovaries?

How many children do you have?

Do you want to have children in the future?

Do you consume tobacco or alcohol? If yes, please indicate the daily amount.

Do you have any disase such as hepatitis, AIDS, diabetes, liver or kidney insufficiency, goiter or hypertension?

Do you have a serious allergy against a medication or food? If yes, please explain in detail.

Do you take medications regularly? If yes please indicate (especially aspirin and other blood-thinners).

Please write at least two telephone numbers we can use to reach you.

Additional remarks, if any.