* Required Complete this survey to help us assess your uterine fibroid symptoms. The answers you give to the survey below can help ARA experts determine if you might be a candidate for uterine fibroid embolization, a leading-edge, non-surgical way to treat uterine fibroids that causes them to shrink drastically, relieving symptoms. Uterine fibroids are benign (noncancerous) tumors that grow on or within the muscle tissue of the uterus. Approximately 20-40% of women 35 years and older have fibroids. Often fibroids are symptom-free but because of size or placement in or around the uterus they may cause severe symptoms that can affect the quality of your life. Heavy bleeding, pain, frequent need to urinate, constipation, and bloating are some of the ways that uterine fibroids can make your life miserable. Fill out and submit the following survey and an ARA interventional coordinator will contact you to determine if uterine fibroid embolization is right for you.Uterine Fibroids Survey: Part 1NoYesI have been told by a medical practitioner that I have uterine fibroids.I believe I might have uterine fibroids.I have not gone completely through menopause.Uterine Fibroids Survey: Part 2NeverSometimesAlwaysI experience heavy bleeding during my menstrual period.I experience prolonged bleeding during my menstrual period.I pass blood clots during my menstrual period.I have severe menstrual cramps.I feel pressure and bloating in my abdominal region.I feel the urge to urinate more than I should.I experience constipation.My symptoms cause me to miss work days.My symptoms cause me to stay home when I want to go out.I feel out of control of my life because of my symptoms.ScorePlease answer all survey questions above to see your results.Interpreting Your Test Score0-6 Points: Uterine Fibroid Symptoms are considered mild. 7-16 Points: Uterine Fibroid Symptoms are considered moderate. 17-23 Points: Uterine Fibroid Symptoms are considered severe. This index is a guide for determining the severity of your symptoms and is only one step in diagnosing uterine fibroids. Regardless of the test score, if you are experiencing uterine fibroid symptoms that interfere with your quality of life, you may wish to see a specialist for further evaluation and additional information regarding this condition.Submit your scores to ARA Diagnostic ImagingWe are here to help you walk through the process of finding out more about your fibroid concerns. Please enter the information below to submit your scores to us and our Interventional Coordinator will follow up with you about your next steps. Yes, I consent to submit my scores Name* First Last Age*Date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.