Medical Survey on Medical Records and Effects of Stilboestrol (DES) as a lactation suppressent

Medical Survey on Medical Records and Effects of Stilboestrol (DES) as a lactation suppressent

This survey has been put together by Origins SPSA t/a Origins Australia to ascertain what, if any, long term medical problems have arisen as a consequence of the administration of Stilboestrol as a lactation suppressant to all mothers. The survey applies to all women. However, we ask whether you are a mother of forced adoption incase there may be observed differences between mothers who had their children removed for adoption and mothers who didn't. The results of the survey will be collated and presented to the government, research organisations, and the media so that the medical profession becomes publicly aware of repercussions to both the mothers and their subsequent children (and grandchildren) regarding the administration of stilboestrol (DES). All information to us will be handled with the strictest confidence and end-to-end encryption is used to secure your data. Your information will be used in accordance with our Privacy Policy, which you can find on our website at www.originsnsw.com
Please enter your full name.*

First NameLast Name
Please provide your email address.*
example@example.com
Your contact phone number (optional).
Please enter a valid phone number.
Your mailing address (optional).

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of birth.*

MonthDayYear
Date
In which year was your baby born?
In What hospital was your baby born?
Please indicate the sex of your baby below:

GirlBoy
Are you a mother of forced adoption practices?

YesNoUnsure
Did you request medication to suppress lactation?

YesNoUnsure
Were you advised you were being given medication to suppress lactation?

YesNoUnsure
If you were advised that you were given medication to suppress lactation, were you told of the name of the medication?

YesNoUnsure
Do your medical records indicate that you were given Stilboestrol?

YesNo
If yes, please specify the duration and dosage.*
If you suspect that you were given Stilboestrol even though it is not indicated in your medical records, please provide details below regarding your suspicions.
If medical records do not indicate that you were given medication to suppress lactation, what method would have been used?

Breast BindingHome RemediesLittle Yellow TabletsOther
If you selected "other", please provide further details below.
Do you recall whether, on discharge from the hospital, you were provided with the remainder of the course of Stilboestrol?

YesNoUnsure/Do not recall
Upon discharge from hospital, were you still lactating?

YesNo
If you selected "Yes" above, how was this suppressed?
Did you ever lactate on hearing any infant cry?

YesNoUnsure/Do not recall

Have you ever had a mammogram which indicated any of the following:

	YES	NO
Calcification of Breast Tissue
Fibrous tissue
Breast Nodules
Pre cancerous cells
Non cancerous cells
Cancerous cells

Have you ever had:

	YES	NO
Bleeding from the nipples, with or without a cancerous diagnosis
Yellow or green discharge during menstruation or at any other time
Cancerous or pre cancerous cervical cancer
A cone biopsy
A Hysterectomy
Malignant tumor
Malignant cancer
Radiation treatment
Chemotherapy
Endometriosis
Adenomyosis
Other Uterine issues such as fibroids, prolapse etc.

If you answered 'Yes' to any of the above conditions, or you experienced similar conditions not specified above, please detail your condition below, including when you were diagnosed and medications/treatments you received.
Describe any effects or side effects you experienced while taking Stilboestrol.
Do you believe, or have had a positive confirmation that any of your children or grandchildren suffered from serious medical conditions, or significant other health concerns, as a result of your exposure to Stilboestrol?

Yes, childrenYes, grandchildrenYes, both children and grandchildrenNoOther
Please detail these medical conditions your children and/or grandchildren, and any confirmed diagnoses and dates of diagnoses below.
Please share any additional comments or information relevant to your medical history and medication experiences.
Do you consent to be contacted at a future date by Origins and any research partners it engages to provide further information regarding your responses to this survey? Further participation will enable Origins to conduct further research regarding the long-term effects from the administration of Stilboestrol to mothers of forced adoption.

YesNo
Should be Empty: