Horizons Clinical Research Center, LLC
Questionnaire
© Copyright 2007 Horizons Clinical Research Center, LLC / All Rights Reserved

    Questionnaire for those interested in participating in a research study for the treatment of
    breast pain.
How did you hear about us?
Are you a pre-menopausal woman at least 18 years of age?
 Yes
 No
Are you pregnant, or have you been pregnant within the past 6 months?
 Yes
 No
Are you currently breastfeeding?
 Yes
 No
Do you experience breast pain around your menstrual period?
 Yes
 No
Do you have regular menstrual periods?
 Yes
 No
Have you ever had a breast implant or breast reduction?
 Yes
 No
Have you had any form of surgery in the past 6 months?
 Yes
 No
Your name:
Your e-mail address:
Your phone number:
Comments:
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