PROPERTY OF
The purpose of this project is to document the financial journey of each participant uterus.  Your responses to the questions below will be used to determine how much money has been invested in maintaining the participant's uterus.  No one outside of the project organizer will have access to the participants responses. 
Sign in to Google to save your progress. Learn more
1. First Name or Initial
3. I would like to remain anonymous.
2. Last Name or Initial
4. How old are you today?
5. How old were you when you started your period?
6. What did you take to control uterine pain/cramps? Please select all that apply.
7. Which period product(s) did/do you use?   Please select all that apply.
8. How old were you when you started using birth control?
9. What type of Birth Control did/do you use?   Please select all that apply.
10. Do have children?
Clear selection
11. If yes, How many ?
12. How were your child(ren) delivered? 
13. How many vaginal deliveries?
14. How many C-section deliveries?
15. Where did you deliver your child(ren)?
16. In what state(s) was your child(ren) born?
17. Have you undergone a hysterectomy?
18. If, Yes, How old were you?
19. Have you been treated for any of the following? Please select all that apply.
20. Have you ever had a miscarriage?
21. If yes, How many?
22. Have you ever had a Dilation and Curettage (D&C)?
23. If yes, How many?
23. Have you ever had an Abortion?
24. If yes, How many?
24. Have you ever undergone In Vitro Fertilization(IVF)?
25. If yes, How many times?
26. Are you receiving Hormone Replacement Therapy?
27. What type of Hormone Replacement Therapy  did you receive?(Select all that apply)
28. If yes, How old were you when you began treatment?
29. Would you like to receive the results of your uterine financial journey?
30. If yes, please provide your e-mail address.
Please feel free to share any emotional or traumatic costs or experiences associated with having a uterus. Examples: Having a diagnosis of PCOS and growing facial hair and that stigma or not going to doctors at all because of how little care there is towards people with uteruses in the medical field.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms