Hysterectomy Medical History Form
Please provide your hysterectomy-related medical history and follow-up details to help us better understand your care needs.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Hysterectomy
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Hysterectomy Performed
*
Please Select
Total Hysterectomy
Partial (Subtotal/Supracervical) Hysterectomy
Radical Hysterectomy
Laparoscopic-Assisted Hysterectomy
Vaginal Hysterectomy
Abdominal Hysterectomy
Other
Reason for Hysterectomy
*
Please Select
Uterine Fibroids
Endometriosis
Cancer (Uterine, Cervical, Ovarian)
Chronic Pelvic Pain
Abnormal Uterine Bleeding
Adenomyosis
Other
Have you had any complications after your hysterectomy?
*
No
Yes (please specify below)
Please describe any post-surgical complications or symptoms (if applicable)
Are you currently experiencing any menopausal symptoms?
*
Yes
No
Not sure
Current Medications (please list all relevant medications)
Name of Current Gynecologist or Follow-Up Care Provider
Submit
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