Menopause Study

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Full Name* This field is required.
First Name
Last Name
2
What is your sex?* This field is required.
Male
Female
Other
3
Hidden - What is your sex?* This field is required.
Male
Female
Other
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Today's Date
Date
Month
Day
Year
6
Hidden - Days Calculation
7
Hidden - Age Calculation
8
Hidden - Age Form Value
9
Hidden - Age Pass/Fail
10
Have you had a regular menstrual cycle in the last 12 months?* This field is required.
Yes
No
11
Hidden - Have you had a regular menstrual cycle in the last 12 months?* This field is required.
Yes
No
12
Do you experience hot flashes and/ or night sweats at least once per day?* This field is required.
Yes
No
13
Hidden - Do you experience hot flashes and/or night sweats at least once per day?* This field is required.
Yes
No
14
Do you experience any of the following symptoms of menopause: Sleep disturbances, mood changes, fatigue and lack of energy, changes in sexual function, urinary changes, weight gain, vaginal changes* This field is required.
Yes
No
15
Hidden - Do you experience any of the following symptoms of menopause: Sleep disturbances, mood changes, fatigue and lack of energy, changes in sexual function, urinary changes, weight gain, vaginal changes* This field is required.
Yes
No
16
Do you have a history of endometriosis, polycystic ovarian syndrome or abnormal pap smear?* This field is required.
Yes
No
17
Hidden - Do you have a history of endometriosis, polycystic ovarian syndrome or abnormal pap smear?* This field is required.
Yes
No
18
Have you been diagnosed with any (other) medical condition?* This field is required.e.g. High blood pressure, high cholesterol, celiac disease, hypothyroidism etc
Yes
No
19
Hidden - Have you been diagnosed with any (other) medical conditions* This field is required.e.g. High blood pressure, high cholesterol, celiac disease, hypothyroidism etc
Yes
No
20
Please specify what medical conditions you have* This field is required.
21
Hidden - Please specify what medical conditions you have* This field is required.
22
Are you currently taking any hormone replacement therapies?* This field is required.e.g. HRT tablets, skin patches, hormonal gels, sprays
Yes
No
23
Hidden - Are you currently taking any hormone replacement therapies?* This field is required.e.g. High blood pressure, high cholesterol, celiac disease, etc
Yes
No
24
Please specify
25
Are you currently taking any medications or supplements?* This field is required.i.e. any medication or supplement e.g. daily blood pressure meds, diabetes, cholesterol, multivitamin, etc
Yes
No
26
Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
27
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
28
Do you suffer from any allergies/intolerances?* This field is required.
Yes
No
29
Hidden - Do you suffer from any allergies/intolerance?* This field is required.
Yes
No
30
Please specify
31
Phone Number* This field is required.
Please enter a valid phone number.
32
Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
33
Would you like to be subscribed to Atlantia's database?* This field is required.Subscribing to this allows us to contact you occasionally via email with study updates or new studies
Yes, Subscribe Me
No, thank you.
34
Consent to mailing list - hidden* This field is required.
35
Where did you hear about the study?* This field is required.
Instagram
Facebook
Previous Participant
Email
Family/Friend
Google Search
Website Ad
Flyer
Other
36
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.
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Score* This field is required.
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Reason* This field is required.
39
Form Status* This field is required.
Should be Empty: