Fields marked with an * are required.

Do you consent to the collection and processing of your personal data, including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. *

Yes

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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.
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.

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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The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

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