Fields marked with an * are required.

First Name *

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Last Name *

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Phone Number *

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Email 

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Date of Birth MM/DD/YYYY *

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Zip Code or Postal Code *

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Have you been told by a doctor that you have endometriosis? * Please select one... Yes - I have Endometriosis No

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Was a medical procedure used to confirm the diagnosis? *
(this procedure may have been referred to as a laparoscopy or a laparotomy) Please select one... Yes No

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Have you ever experienced painful symptoms (such as painful periods, severe cramping, pain between periods, painful sex, painful urination, or bowel movements) because of endometriosis? * Please select one... Yes No

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Do you or did you used to, regularly smoke or use nicotine products (e.g. cigarettes, e-cigarettes, vaping, nicotine replacement therapy (nicotine gum, lozenge, patch etc.))? * Please select one... Yes – I REGULARLY smoke or use nicotine products Yes – I used to REGULARLY smoke or use nicotine products No

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Have you been diagnosed by a doctor, or treated for major depressive disorder (MDD) OR a post-traumatic stress disorder (PTSD) episode in the past 2 years? * Please select one... Yes - depression Yes - PTSD No

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Have you ever been diagnosed, by a doctor, with Schizophrenia or Bipolar Disorder? * Please select one... Yes - Schizophrenia Yes - Bipolar Disorder No

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Have you been diagnosed, by a doctor, or treated for any of the following? *
Please select any that apply. Hold down CTRL to select more than one.
Please only select conditions which have been diagnosed by a doctor. Osteoporosis or other bone disease Hyperthyroidism Cancer (except basal cell skin cancer) Stroke heart attack or blood clots Anorexia Nervosa Cirrhosis of the liver None of the above

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Have you had any of the following surgical procedures? *
Please select all that apply. Hold down CTRL to select more than one. Hip replacement in BOTH hips Hysterectomy Bilateral Oophorectomy (BOTH ovaries removed) None of the above

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Have you been diagnosed (by a doctor) with any other medical conditions? *
Please list below or type ‘none’.

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If you are taking any medications for your endometriosis or other health conditions, please list them below.

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Are you using hormonal birth control (either pills, an IUD or an implant under your skin)? * Please select one... Yes – I am using birth control pills Yes – I have an IUD Yes – I have a birth control implant No

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In order to participate in the study, would you be willing to discontinue use of your birth control pills or have your IUD or birth control implant removed for the duration of the study?
(Please note, the study team will discuss this with you further if you qualify for the study. Other study specific birth control pills and non-hormonal methods of birth control may still be used.) Please select one... Yes No I don't know - I need more information from the study team

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Would you be willing to use non-hormonal birth control (for example: condoms and spermicide), as required during your participation in the study? (Please note, the study team will discuss this with you further if you qualify for the study.) * Please select one... Yes No

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Do any of the following apply to you? *

• Currently pregnant
• Breastfeeding

Please select one... Yes No

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Are you currently participating in a clinical trial for an investigational drug or device? * Please select one… Yes No

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What is the best day/time to reach you via telephone (we know you are busy)? *

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Do you consent to the collection and processing of your personal data (including information about your health, race and ethnicity (as applicable); including disclosure to our Research Partners) for the purpose of recruitment into clinical research studies? *

Yes

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