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
    endometriosis.
How did you hear about us?
Are you female at least 18 but not older than 49 years of age?
 Yes
 No
Are you pregnant?
 Yes
 No
Have you had a history of regular menstrual cycles within the past
six (6 ) months?
 Yes
 No
Do you agree to use two (2) forms of non-hormonal contraception
(e.g., condom with spermicide) during the study?
 Yes
 No
Have you had a hysterectomy (uterus removed) or bilateral
oopherectomy (both ovaries removed)?
 Yes
 No
Have you been pregnant within the past six (6) months?
 Yes
 No
Are you currently breastfeeding?
 Yes
 No
Do you have chronic pelvic pain that is not caused by endometriosis (e.g.,
uterine fibroids)?
 Yes
 No
What is your approximate weight?
What is your approximate height?
Your name:
Your e-mail address:
Your phone number:
Comments:
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