* Indicates required field

Interviewed By:*

What is your name?*

How old are you?* please choose 21 22 23 24 25 26 27 28 29 30 31 32

How did you hear about our program?*

Address:*

City:* State:* please choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:*

Phone:*Alt. Phone

Ok to leave message?* please choose yes no

Email:*

Are you:* please choose single married divorced relationship

Height:* Weight:* BMI:

Race/ethnicity?* please choose African American Asian Caucasian Hispanic or Latino Pacific Island Other

Do you smoke?* please choose yes noIf yes, how much per day? please choose 0-5 cigarettes half a pack whole pack 1 or more packs

Have you ever smoked?* please choose yes no

If yes, how long ago did you quit? (must be 6 months+)

Do you have regular periods?* please choose yes no Length of cycle?*

LMP:*

What method of birth control are you using now?*

Have you ever used BCPs?* please choose yes no

If yes, which ones? If yes, how long?

Would you be willing to stop birth control temporarily?* please choose yes no

Have you ever been pregnant?
What were the outcomes?
(select all that apply) G P T SAB TAB L E

Births:*

Have you ever had any medical problems?*

Have you ever had any psychological problems?*

Surgeries?*