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)?
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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.)
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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.)
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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?
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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.
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Yes No
I find myself oversleeping or taking naps, or I'm not sleeping well at night.
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Yes No
I feel very overwhelmed or out of control.
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Yes No
During the week leading up to my period, I am very bothered by at least 2 of the following physical symptoms:
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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?
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Yes No
Covid-19 Screening questions:
The option "
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!
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