Limited Market Release Procedure Feedback Form

Please Note: No Patient, physician / facility names or unique identifiers should be recorded anywhere on this survey as this is a blinded survey and all such information must remain confidential.

Hologic Representative:
Date Survey Completed:
Procedure details
Site of Service:
Previous experience with MyoSure?:
If yes, how many MyoSure procedures have you performed to date:
Age of patient:
Device used:
Size: cm   x  cm   
+ Add another pathology
Reason for treatment
(check all that apply):   

Cervical dilation required?
If Yes, max dilation: mm
Anesthesia type
(check all that apply):   

Fluid Management System:

If other, specify:
Flow rate: Low ml/min High ml/min 
Intrauterine pressure: Low mmHg High mmHg 
Vacuum pressure: Low mmHg High mmHg 
Total fluid:   cc  
Fluid deficit:   cc  
Procedure time
(Scope in – Scope Out):
   minutes  seconds
Treatment cutting time
(from MyoSure Control Box Display):
   minutes  seconds
Percent of pathology removed:   %
Methodology typically used for the removal of this pathology (check all that apply): 

Ease of Use
The system was easy to assemble:

Insertion of the scope was easy:

The device was easy to operate:

Visualization during the procedure was excellent:

The device was able to remove the tissue faster than my standard methodology for removing this tissue:

If you prefer the device over your standard methodology, please indicate the reason(s) (check all that apply):

Other, specify:
If you prefer your standard methodology over MyoSure, please indicate the reason (s) (check all that apply):

Other, specify:
I would use this device again:

I would recommend the use of this device to my colleagues:

Additional comments: