Fibroid Embolization - History Form

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Gynecologic and Medical History

             Instructions for Use

You may use this page in three different ways to submit information.

Print this page directly from your computer screen, fill in the answers by pen and either Mail or FAX the completed form to us.
Fill out this form while on your computer, print the page on completion and Mail or FAX the form to us.

Send Attn:
Program Coordinator

Mail to

The Fibroid Embolization Center
Department of Radiology
Northern Westchester Hospital
400 East Main Street, Mt. Kisco, NY 10549

Fill out this form while on your computer, then click the "Submit" button and it will be sent automatically via the Internet to our Nursing Staff at the UAE Unit.

All required Fields are marked with an asterisk

Identifying Data

*Name:

*Address:

*City:      *State:

*Zip:

Telephone Number:

*Home:      Work:

Best time to reach me is:
                                               If possible, please place this between 9-5 (EST), M - F

*Date of Birth:

*Email Address

**All required Fields are marked with an asterisk**
	Identifying Data Name: Address: City: State: Zip: Telephone Number: Home: Work: Best time to reach me is: *If possible, please place this between 9-5 (EST), M - F* Date of Birth: Email Address

Your Symptoms
please describe them

Gynecologic History
check all appropriate boxes

Have you ever had any of the following:

D&C    Hysteroscopy    Endometrial Biopsy

Myomectomy       Hormonal Therapy       Lupron

Pelvic Ultrasound       M.R.I.          Previous UAE

Menstruation:

I am premenopausal and still menstruating -

I am postmenopausal and no longer menstruating

Medical History
check all appropriate conditions

Diabetes    High Blood Pressure     Mitral Valve Prolapse

Easy bruising

Your Approximate Weight     lbs, and Height

Please answer the following 4 Medical Questions

(1) If you have any cardiac condition, please describe the problem:

(2) Do you have any other medical conditions? Please describe them.

(3) Please list all medications (foods or other items) to which you are ALLERGIC.

(4) Please list all medications that you are currently taking (include frequency and dosage).