post-embolization recovery

Is this an original or revised submission?

Original

Revised

Name of the Person Entering Data into this CRF

First Name

Last Name

Date of Embolization Procedure

MM

DD

YYYY

Did the patient experience pelvic pain after UFE?

Yes

No

Date of Pain Assessment

MM

DD

YYYY

Time of Pain Assessment

Hour

Minute

Second

AM PM

Did the patient experience nausea or vomiting after UFE?

Yes

No

Did the patient experience fever after UFE?

Yes

No

Did the patient experience a discharge after UFE?

Yes

No

Date of Resolution of Post-UFE Discharge

MM

DD

YYYY

Did the patient receive any medications following UFE that was in addition to the normal post-procedure medication regimen?

If the answer to this question is "yes" please be sure to specify these medications on the concomitant medication sheet and document the indication for this medication on an "adverse event" CRF if needed.

Yes

No

Overnight Hospitalization

Yes

No

If "yes" for overnight hospitalization, was the hospitalization planned?

Yes

No

Date of Hospital Discharge

MM

DD

YYYY

Attestation *

I approve the data entered into this CRF and attest to its accuracy.

Date of Completion

MM

DD

YYYY