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The Missed Menstrual Periods Study at Mayo Clinic Florida: Pre-screening questionnaire

Hello,

Thank you for your interest in the Missed Menstrual Periods Study at Mayo Clinic Florida. We are currently accepting participants. Please, fill out this form to determine your qualification for this study. We will contact you as soon as possible.

Thank you for your time!

What is your name?

How old are you?

* must provide value

What is your height?

* must provide value

What is your weight?

* must provide value

What is your BMI?

* must provide value

View equation

Do you recall the first day of your last period?

* must provide value

Yes No

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If yes, please provide a date

M-D-Y

If not, please provide an approximate time

When you were getting your periods, were they regular (occurring every 24-35 days)?

* must provide value

Yes No

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Have you missed at least 3 consecutive periods?

* must provide value

Yes No

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If you have not missed 3 consecutive periods, continue with the following:
How many?

Have you seen a doctor about why your periods are irregular?

* must provide value

Yes No

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Have you received a diagnosis for why your periods are irregular?

* must provide value

Yes No

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If yes, what was the diagnosis?

Functional Hypothalamic Amenorrhea

Polycystic Ovarian Syndrome

Hypogonadotropic Hypogonadism

Premature Ovarian Failure

Hypothyroidism

Prolactinoma

Rathke Cleft Cyst

I do not recall

I do not desire sharing this information

Other condition

Have you had any testing done to confirm this diagnosis?

* must provide value

Yes No

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If yes, please write down the values of your hormonal profile or any important findings.

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Do you tend to grow dark, coarse hair on your face or upper body?

* must provide value

Yes No

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Do you currently use hormone contraceptive (such as birth control pill, patch or ring) or any type of estrogen or progesterone therapy?

* must provide value

Yes No

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How did you hear about our study?

* must provide value

Facebook

Instagram: which account?

Twitter

Flyer

Word of mouth

Physician referral

Health fair / conference

Electronic Advertisement Boards around Mayo Clinic Campus

Podcast: which one?

Other:

What is your occupation?

* must provide value

Which country are you located in?

* must provide value

Which state/province are you in?

* must provide value

Which city are you living in?

* must provide value

Please, provide an email address to contact you.

* must provide value

Would you mind sharing your phone number with us?

Would you like to be considered in other related studies?

* must provide value

Yes No

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.