BumptUp Study Qualification

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1990)

City and State

Consent for future studies?

Yes No

What other types of studies would you be interested in?

List comma separated keywords

Are you currently pregnant?

Yes No

How many weeks pregnant are you?

Are you pregnant with a single baby?

Yes No Not yet had first scan

What is your due date?

Format: Month/Day/Year (e.g., 01/15/2026)

Are you at least 18 years old?

Yes No

Do you reside in Bowling Green, KY?

Yes No

Are you a patient at Graves Gilbert Clinic, Women's Health, or Fairview?

Yes No

If you are a clinic patient, who is your obstetrician?

If you are not a clinic patient, are you willing to provide chart data?

Yes No

Are you able to self-report clinical results?

Yes No

Can you communicate and consent in English?

Yes No

Do you have access to a smartphone?

Yes No

Are you willing and able to participate in study procedures?

Yes No

Do you have any medical condition or limitation that would preclude your participation?

Yes No

Is there any other reason you cannot safely participate in this study?