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Uterine Fibroid Study Questionnaire
Please complete the form to determine if you will be selected participate in this study
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Mobile phone number (will only be used if selected)
*
Your answer
What is your ethnicity?
*
Black or African American
White
Hispanic or Latino American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Other
Other:
What is your age?
*
18 - 24
25 - 34
35 - 44
45 - 54
55 +
Other:
Have you been medically diagnosed with uterine fibroids in the past 10 years?
*
Yes
No
Has your doctor or health care professional recommended surgery to remove fibroids or hysterectomy?
*
Fibroid removal only
Full or partial hysterectomy
Other
Have you been a permanent resident of the United States for at least the past 10 years?
*
Yes
No
If selected, are you able to participate in a virtual interview for 1-1 1/2 hours?
*
Yes
No
Send me a copy of my responses.
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