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VWD/HMB Study
1
I have been diagnosed with von Willebrand Disease Type 1.
*
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True
False
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2
I have a history of heavy menstrual bleeding.
*
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True
False
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3
I am currently on hormone therapy.
*
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Example: birth control pills, patch, injection, hormonal IUD, etc. Note: this does not include the Copper IUD.
True
False
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4
I am between 18 and 45 years of age.
*
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True
False
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5
I have been pregnant within the past 3 months.
*
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True
False
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6
I am currently lactating.
*
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True
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7
I have a history of chronic tobacco use, ingested nicotine via smoking, vaping, smokeless tobacco, or nicotine patches in the past 3 months.
*
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True
False
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8
I have a pacemaker, cochlear implant, or implanted neurostimulation system.
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True
False
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9
I have reliable access to an internet-enabled device.
*
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True
False
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10
Name
*
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First Name
Last Name
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11
Email
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12
Phone Number
Please enter a valid phone number.
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13
By submitting this form:
You confirm your previous responses are true to the best of your knowledge.
You consent to being contacted via email by the clinical study team to be evaluated for the clinical
trial, if eligible.
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