Endo-Epic Study Screener

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/2000)

City and State

ZIP Code

Contact for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

How did you hear about us?

Facebook Instagram Physician/Provider Friend or Family UM Health Research Flyer Radio Other

You selected other, where else did you hear about us?

Do you feel comfortable answering medical questions in English?

Yes No

Are you willing to stop taking hormonal birth control (e.g., pill, vaginal ring, Mirena®, Kyleena®) for at least one menstrual period?

Yes No

Are you willing to take MyFembree (Relugolix Combination Therapy)?

Yes No

Are you currently in natural menopause (no menstrual period for 1+ year)?

Yes No

Are you currently pregnant or planning to become pregnant in the next year?

Yes No

Have you ever had a hysterectomy or removal of both ovaries?

Yes No

Are you willing to travel to Ann Arbor for 4 in-person visits? Please note that travel reimbursement is available for participants traveling long distances.

Yes No

Are you willing to have a brain MRI (about 1 hour), 3 times during the study?

Yes No

Are you willing to do sensory testing 3 times during the study?

Yes No

Have you been diagnosed with Endometriosis?

Yes No

How were you diagnosed with Endometriosis?

Imaging (Ultrasound or MRI) Surgery Based on symptoms only Other

You selected other, what other way was your endemetriosis diagnosed?

When were you diagnosed?

Within the last 10 years More than 10 years ago

If more than 10 years ago, have you had recent imaging or surgery (in past 10 years) confirming you still have Endometriosis?

Yes No

On a scale from 0 to 10, what has been your average non-menstrual pelvic pain over the past 6 months?

Have you used any injectable hormone therapy (e.g., Depo-Provera) in the past 6 months?

Yes No

Would you like us to contact you after you’ve been off injectable hormone therapy for 6 months?

Yes No

Please tick all where you will be available for a screening call