1.
What age were you when you have your UAE procedure?
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
2.
How long ago did you have your UAE procedure? (e.g. 2 years 5 months)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Years
1
2
3
4
5
6
7
8
9
10
11
Months
3.
Did you have your UAE procedure done by a private hospital or clinic?
Yes
No
4.
Name of the hospital or clinic who performed your UAE
5.
Please list the symptoms that you expected or hoped UAE to relieve
6.
Overall, how HAS the UAE procedure affected your fibroid symptoms?
(Please select ONE)
My symptoms Improved
My symptoms were Unchanged
My symptoms Worsened
7.
Please tell us how UAE HAS changed your life with respect to the following:
7a.
Physical symptoms (e.g. Pain, heavy bleeding...)
Worse
No Effect
Some improvement
Good
7b.
Day to day activities (e.g. work)
Worse
No Effect
Some improvement
Good
7c.
Quality of life (e.g. lifestyle, social life)
Worse
No Effect
Some improvement
Good
7d.
Emotional health / wellbeing (e.g. mood, depression, anxiety)
Worse
No Effect
Some improvement
Good
Please, describe your experience in other areas NOT covered above.
8.
Did or do you have any concerns about UAE procedure, in terms of risks of SERIOUS side-effects or complications?
(Please select ONE)
Yes, significant concerns
Yes, minor concerns
No concerns
If YES Please describe your concerns.
9.
Did you experience any side-effects or complications after your UAE procedure?
(Please select ONE)
Yes, significant side-effects
Yes, minor side-effects
No
If YES, when did they occur?
If YES , Please also list those side-effects or complications.
Were these side-effects resolved in time?
Yes
No
How were they resolved.(if you do not know for sure, just say don't know.)
10.
Did you have a subsequent hysterectomy as a result of SERIOUS complications?
Yes
No
Not Applicable
11.
Would you consider a repeat UAE for re-growth of fibroid, if this option is medically viable?
Yes
No
Please explain your answer
12.
Since your UAE treatment for fibroids, if your fibroid symptoms RETURNED , what treatment did you eventually receive?
(Please select ONE)
Hysterectomy
Myomectomy
Hysteroscopic resection
Repeat UAE
Not Applicable
Please explain your answer
13.
Would you recommend UAE procedure to another patient with your condition?
(Please select ONE)
Yes
No
14.
Have you recommended the UAE procedure to others?
(Please select ONE)
Yes
No
What might you tell them if they ask you about the procedure?
15.
Please tell us anything else that you think it is important for BFT (as a patient representative) to bring to the attention of NICE or a medical professional body.
16.
Did someone complete this form on your behalf?
(Please select ONE)
Yes
No