FUS-Center

am Klinikum Dachau

FUS-Center am Klinikum Dachau, Krankenhausstrasse 15, 85221 Dachau

Dr. Matthias Matzko, Radiologie

Krankenhausstrasse 15
D-85221 Dachau
Fon: +49 (0)8131/ 76 392
Fax: +49 (0)8131/ 61 69 689
info@uterusmyome.de
www.uterusmyome.de

Dear Patient,

Please take a moment to fill out this questionnaire. Thank you!

Surname/Prename: _________________________________ Date of birth: ________________________

Adress: ______________________________________________________________________________
Phone number: ______________________________

Email: __________________________________

Height:

__________

Weight: ___________

Allergies:

___________________________________________________________________________

Since when you have problems with fibroids? ______________________________________

Do you have scars from previous surgery at the abdominal wall? Or do you have a tattoo at
the stomach?______________________________________________________________

Under what complaints do you suffer?

q

Pain during the menstruation

Strong bleeding during menstruation

Pain during the menstrual cycle

pressure on the bladder/intestine

Further complaints: ______________________________________________

_______________________________________________________________________
Do you like to have children:
q yes
Are your menopause already occurred: q yes

q no
q no

Amper Kliniken AG, Sitz der Gesellschaft: Dachau,

Vorstandsvorsitzender: Bernward Schrter, Vorstand: Nicolas von Oppen, Aufsichtsratsvorsitzender: Dr. Dr. Martin Siebert
Handelsregister: HRB Nr. 157 279, Registergericht Mnchen