premature ovarian failure, premature menopause, early menopausepremature ovarian failure, premature menopause, early menopause

Infertility Trials DHEA Application

We are asking you to fill out this form because you have expressed an interest in participating in a clinical trial. Women who consent to participate in this trial will be randomly assigned to help us study the use of DHEA in treating premature ovarian failure.

* Answer required

Are you interested in participating in this study? *
(If you answer "No," you are finished with this form.
Yes
No, I do not want to participate.

Do you understand that participants will receive either DHEA or a Placebo (sugar pill)? *

Please enter your first name: *

Please enter your last name: *

Please enter your Email address: *

What is your phone number?

What is your cell phone or work number? *

What is your zip code?

What is your birthdate? (mm/dd/yy)*

How old are you today?

Have you been living in this area at least 18 months?

Are you presently enrolled in any other research study? *

How would you identify your racial group? *
( If you are of mixed background, which do you do identify with the most?)

Do you consider yourself to be Hispanic? *
(Ethnic Hispanic individuals include many different racial backgrounds.)

How old were you when you had your first period? *

Are your cycles shorter than 24 days? *

Are your cycles longer than 34 days? *

How many times have you been pregnant? *

Any miscarriages? *





Other:



Have you ever had a tubal pregnancy? *



Have you ever had surgery on your uterus or fallopian tubes?
Are you married or with a partner? *

How long have you been trying to become pregnant? *

Do you have at least one open fallopian tube?
When was the test of your tubes performed?

If you were tested, what kind of test was performed?

Does your husband/partner have a normal semen
analysis? *



How much do you weigh (in pounds)? *

How tall are you in inches? *
(5" equals 60-inches; 5' 2" equals 62, etc.)

By placing your initals in the space below you agree to allow us to contact you further about this study.

Thank you for filling out this form. If you have had a test of your tubes and your husband has had a normal semen analysis, please have your doctor fax your reports to 312.876.1804, c/o DHEA Inferility Trial; or email the documents as attachments to mdixon@infertilitytrials.com; After we have reviewed your answers to these questions and have received copies of your previous testing, we will call you to come to our office in Manhattan to begin the study.