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Patient Info
Current Trials
Meet the Team
Sponsor/CRO
John Whitfield, MD
Patient Portal
Blog
Contact Us

Contact Us

Fort Worth Texas Signature Gyn Services Women's Health Clinical Trials Research Studies Fort Worth Texas

Signature Gyn Services

Visit us at The Professional Pavilion at Baylor Scott and White All Saints Hospital

1250 Eighth Avenue Suite 540 Fort Worth, TX 76104
(817) 927-2229
(855) 554-0888
[email protected]

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Signature Gyn Services Women's Health Clinical Trials Research Studies Fort Worth Texas

Women's Health Clinical Resarch Site

Contact Information

(817) 927-2229
[email protected]
1250 8th Ave Suite 540 Fort Worth, TX
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Last

Email *

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Signature Gyn Services Women's Health Clinical Trials Research Studies Fort Worth Texas

Endometriosis Study

Name *

First

Last

Date of Birth *

Phone *

Date of last period

What do you currently use for birth control?

If you have had a mammogram please list date of most recent

If you have ever been pregnant please list date of deliveries (please include any dates for miscarriage or abortions)

Have you ever participated in a clinical trial before?

Yes
No

Please list all medications you currently take and what you take them for:

Have you had surgery for endometriosis *

Yes, and my physician told me they found endometriosis
Not for endometriosis but I had surgery and they found endometriosis
I have not had surgery but my doctor told me that is what he/she believes is causing my pain
I have not been told I have endometriosis but believe that I may

From the beginning of one period to the beginning of the next period would you say that they are 21-35 days apart?

Yes
No

I am/have had (Check all that apply)

currently breastfeeding, pregnant or trying to become pregnant
less than 6 months post-partum, post-abortion, or post-lactation
moderate to severe pelvic pain or painful periods
had a hysterectomy
removal of my ovaries
major schizophrenia or bipolar disorder
major depression or PTSD episode in the last 2 years
previous suicidal attempts
tried Lupron, Myfembree, Orlissa, or DepoProvera for endometriosis and it did not help
undiagnosed bleeding
drug or alcohol abuse in the last 12 months
cancer (other than basal cell carcinoma of the skin)
bone conditions (osteoporosis, osteopenia, or other bone disease)
uncontrolled thyroid disease, parathyroid disease, anorexia nervosa
low trauma fractures, bilateral hip replacement, spinal surgery or spinal hardware, severe scoliosis
chronic pain conditions other than endometriosis

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