Cell Phone Number
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Address(Please include house number, street, city, state, ZIP code.)
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Email Address
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How did you hear about this study?
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If other, please specify:
If by flier, where did you see the flier?
Are you between the ages of 18 and 50?
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Yes No
Date of birth:
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Today M-D-Y
Is your biological sex female?
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Yes No
Do you experience a menstrual period about once per month (every 24 to 35 days)?
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Yes No
If yes, what is the typical length of your menstrual cycle -- the number of days between the start of one menstrual bleeding and the start of the next month's menstrual bleeding (note: 28 days is the average)?
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What was the first day of your most recent menstrual period (i.e. the date that bleeding started)? Please enter date.
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Today M-D-Y
What is the date that you expect your next menstrual period (bleeding) to start? Please enter date.
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Today M-D-Y
Have you been pregnant in the past 6 months?
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Yes No
Are you currently breastfeeding?
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Yes No
If yes, how many months have you been breastfeeding?
Have you ever been diagnosed with a psychotic disorder (schizophrenia, schizoaffective disorder, major depression with psychotic features)?
* must provide value
Yes No
schizophrenia
schizoaffective disorder
major depression with psychotic features
Do you currently take hormone-based medications, including steroid hormones or hormonal contraception*? (*Hormonal contraception includes oral contraceptive pills ("the pill"), hormone patch, vaginal ring, hormone injection such as Depo-Provera, or an intrauterine device (IUD) that contains hormones such as Mirena, Kyleena, Liletta, or Skyla.)
* must provide value
Yes No
Hormonal medication name:
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In the past have you taken hormone-based medications, including steroid hormones or hormonal contraception*? (*Hormonal contraception includes oral contraceptive pills (“the pill”), hormone patch, vaginal ring, hormone injection such as Depo-Provera, or an intrauterine device (IUD) that contains hormones such as Mirena, Kyleena, Liletta, or Skyla.)
* must provide value
Yes No
Past hormonal medication name:
Past hormonal medication dosage:
Month and year last taken:
Today M-D-Y
Do you currently take any psychiatric medications?
(*This includes prescribed medications to manage mood, anxiety, or mental health.)
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Yes No
Psychiatric Medication Name:
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In the past have you taken any psychiatric medications?
* must provide value
Yes No
Past psychiatric medication name:
* must provide value
Month and year last taken:
* must provide value
Today D-M-Y
Do you currently take any other medications?
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Yes No
Other medication name (1):
Other medication dosage (1):
Length of time taken (1):
Other medication name (2):
Other medication dosage (2):
Length of time taken (2):
Other medication name (3):
Other medication dosage (3):
Length of time taken (3):
I feel much more depressed or down in my mood.
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Yes No
I feel anxious, tense, "keyed up," or "on edge".
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Yes No
I feel hypersensitive (to rejection or criticism), or I feel very unstable and unpredictable in my emotions.
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Yes No
I feel much more irritable or I get angry easily.
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Yes No
I am much less interested than usual in my hobbies and daily activities.
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Yes No
I find it much harder to concentrate on things.
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Yes No
I feel much more tired and low in energy.
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Yes No
I have a tendency to crave carbohydrates or go on eating binges.
* must provide value
Yes No
I find myself oversleeping or taking naps, or I'm not sleeping well at night.
* must provide value
Yes No
I feel very overwhelmed or out of control.
* must provide value
Yes No
During the week leading up to my period, I am very bothered by at least 2 of the following physical symptoms:
-Breast tenderness or swelling, -Increased headaches, -Joint or muscle pain, -Feeling bloated, or -Weight gain.
* must provide value
Yes No
Do most of the symptoms you checked disappear within 3 days of the start of your period?
Yes No
When you are having these symptoms, do they interfere with your ability to function normally and do your daily activities?
* must provide value
Yes No
Covid-19 Screening questions:
Do you have new onset of any TWO of the following symptoms: fever, cough, sore throat, shortness of breath, muscle aches, diarrhea or headache?
Were two or more symptoms present?
OR
Do you have ONE of the above symptoms AND exposure to a person confirmed to have COVID-19, live in a long term care facility (e.g., nursing home, skilled nursing facility, assisted living, rehabilitation unit), referred from a correctional facility or are a resident of a homeless shelter?
If yes, which apply to you?
OR
Do you have new, unexplained loss of taste or smell?
OR
Have you had a positive COVID-19 test within the past 14 days?
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Do you have new onset of any TWO of the following symptoms:
Were two or more symptoms present?
Yes No
Do you have ONE of the above symptoms AND exposure to a person confirmed to have COVID-19, live in a long term care facility (e.g., nursing home, skilled nursing facility, assisted living, rehabilitation unit), referred from a correctional facility or are a resident of a homeless shelter?
Yes No
If yes, which ones apply to you:
Do you have new, unexplained loss of taste or smell?
Yes No
Have you had a positive COVID-19 test within the past 14 days?
Yes No
YES to any of the questions Patient has No Primary Care Provider (PCP): Instruct the patient to call the COVID 19 Response Team at 443-997-9537
Patient Has a Hopkins PCP: Connect the patient with the PCP office.
Stop the screening process for COVID-19.
Thank you for completing this screening!
Please click the "Submit" button below to submit your survey. A member of the study team will contact you to discuss the next steps.