Women's Health Study

1
Full Name* This field is required.
First Name
Last Name
2
What is your age?* This field is required.
3
Age - Form Value
4
Age - Pass/Fail
5
Are you pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
N/A - Male
6
Hidden - Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No
N/A - Male
7
What best describes your menstrual cycle* This field is required.
Regular/Predictable
Irregular/Unpredictable
No period due to long-acting birth control
Peri/Post-Menopausal
8
Hidden - What best describes your menstrual cycle* This field is required.
Regular/Predictable
Irregular/Unpredictable
No period due to long-acting birth control
Peri/Post-Menopausal
9
Please select the option that best describes you in relation to contraception* This field is required.
IUD (Coil)
Oral contraception (The pill)
Contraceptive injection
Contraceptive Patch
Implant (Bar)
Vaginal Ring
None
Other
10
Hidden - Please select the option that best describes you in relation to contraception* This field is required.
IUD (Coil)
Oral contraception (The pill)
Contraceptive injection
Contraceptive Patch
Implant (Bar)
Vaginal Ring
None
Other
11
Are you willing to abstain from using any insertive vaginal products for two menstrual cycle lengths (approximately 56 days) following the Vaginal Microbiota Transplant?* This field is required.
Yes
No
12
Hidden - Are you willing to abstain from using any insertive vaginal products for two menstrual cycle lengths (approximately 56 days) following the Vaginal Microbiota Transplant?* This field is required.
Yes
No
13
Have you been diagnosed with any medical conditions?* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
14
Hidden - Have you been diagnosed with any (other) medical conditions* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
15
Please specify what medical conditions you have been diagnosed with* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc.
16
Are you currently taking any medications or supplements?* This field is required.e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
Yes
No
17
Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
18
Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
19
Have you previously had any gynaecological surgery or conditions?* This field is required.
Yes
No
20
Hidden - Have you previously had any gynaecological surgery or conditions?* This field is required.
Yes
No
21
Please specify the type of surgery you had performed or condition you have diagnosed* This field is required.
22
Phone Number* This field is required.
087/021
1234567
23
Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
24
Would you like to be subscribed to Atlantia's database?* This field is required.
Yes, Subscribe Me
No, thank you.
25
Consent to mailing list - hidden* This field is required.
26
Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Yaycork
Family/Friend
Google Search
Website Ad
Flyer
UCC
MTU
Red FM
Cork Independent
96FM/C103
Classic Hits
Other
27
Consent to Privacy Notice* This field is required.We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com Do you consent to Atlantia Food Clinical Trials Ltd. processing the information you have provided in this form for the purpose of assessing your eligibility for this trial
28
Score* This field is required.
29
Reason* This field is required.
30
Form Status* This field is required.
Should be Empty: