Beacon Interest — Women's Health

Who is completing this form?

Myself Parent/legal guardian Spouse/partner Other caregiver

Full name

Email address

Mobile phone number

US format; used for SMS + call

Preferred contact method

Phone call Text message Email

Best time to reach you

Morning Afternoon Evening Anytime

Date of birth

Derives age for eligibility.

Sex assigned at birth

Female Male Intersex Prefer not to say

Gender identity (optional)

Woman Man Non-binary Prefer to self-describe Prefer not to say

City and state

ZIP / postal code

Primary geo-match signal.

How far would you travel for a study?

Under 10 mi 10–25 mi 25–50 mi 50+ mi Remote/at-home only

Preferred language

English Spanish Other

Preferred language (other)

I agree to be contacted about future research opportunities that may fit me.

I agree to be contacted about future research opportunities.

I have read the privacy notice and understand my information is stored securely and I can opt out anytime.

I have read and accept the privacy notice.

Which apply? Choose any.

Other women's-health condition (please specify)

Are you currently pregnant?

Yes No Currently trying to conceive

Menopausal status

Pre-menopausal Perimenopausal Post-menopausal Not sure

Number of prior pregnancies

[Menopause] Hot flashes per day

None 1–5 6–10 10+

[Menopause] Currently on hormone therapy (HRT)?

Yes No

[Endometriosis] Confirmed by laparoscopy/surgery?

Yes No Not sure

[Endometriosis] Pelvic pain severity

Mild Moderate Severe

[PCOS] Symptoms. Choose any.

Irregular periods Weight gain Excess hair Acne Fertility issues

[Infertility] Months trying to conceive

[Infertility] Prior treatments. Choose any.

None Clomid/letrozole IUI IVF Other