referrals

Endometriosis Study

Name *

First

Last

Date of Birth *

Phone *

Date of last period

What do you currently use for birth control?

Date of your last Pap smear

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?

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

Have you had surgery for endometriosis

Yes, I had a laparoscopy or laparotomy 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 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?

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 with or without ovaries removed
removal of my ovaries
major schizophrenia or bipolar disorder
major depression or PTSD episode in the last 2 years
previous suicidal attempts
tried Lupron, 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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