The code block below illustrates how one might use # and // as comments in your logic and calculations.

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jsPsTKG6m3yKFoudUzKQtcaDRctkUeAp9NRxFfZZCHxSFtkakkry3kerJXzHnbpHD69bceSeRk6TpUVwZz5DysSAzk96IShUE5wQE

Preliminary Screening Questionnaire

The Neuroendocrine Unit at Massachusetts General Hospital is currently recruiting participants for the research study "Transdermal Estrogen in Older Premenopausal Women with Anorexia Nervosa." Your answers to the questions below will help us determine whether or not you are eligibile to participate in this research study. Please answer as many of the questions as you can, but it's ok if you need to leave some blank. Your responses will be kept confidential. If you have any questions or concerns regarding the research study or this survey, please contact Megi Resulaj at (617) 724-5406 or mresulaj@mgh.harvard.edu

Thank you!

Please indicate your sex:

Female

Male

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What is your approximate height?

What is your approximate weight?

Have you ever been diagnosed with anorexia nervosa?

Yes

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Do you have osteoporosis or low bone density?

Yes

Not sure

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Have you ever broken any bones?

Yes

Not sure

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Which bone(s) have you broken and when did the break(s) occur?

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Are you currently having regular menstrual periods?

Yes

Not sure

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What is the approximate date of your most recent menstrual period?

M-D-Y

Are you currently pregnant or breastfeeding?

Yes

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Do you have a history of any other medical conditions?

Thyroid disease

Bone disease

Cushing's syndrome

Diabetes

Cardiopulmonary disease

Bradycardia

Liver disease

Digestive problems (such as GERD or IBS)

Kidney disease

Anemia

Cancer

Skin conditions

Musculoskeletal symptoms

Seizure

Stroke

Brain tumor

Depression

Anxiety

Blood clot

Stroke

Heart Attack

Migraine headaches

Clotting disorder

Hereditary angioedema

Breast cancer

Family history of breast cancer

Other

Have you ever received radiation therapy?

Yes

Not sure

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What type of radiation therapy did you receive?

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Do you take any medications and/or dietary supplements?

Yes

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Please list the medications and/or dietary supplements you are taking:

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In the past 3 months have you taken steroids and/or immunosupressants?

Yes

Not sure

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In the past 3 months, have you used any form of hormonal contraception?

Yes

Not sure

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In the past six months, have you received Depo-Provera injections?

Yes

Not sure

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In the past year, have you taken bisphosphonates?

Yes

Not sure

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Are you allergic to any foods, medications, or latex?

Yes

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Please list any allergies that you have:

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Additional information or comments:

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Name:

Date of birth:

Phone number:

Email address:

Mailing address:

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How did you find out about this research study?

Is it ok for us to contact you about other research studies that you may be eligible for?

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.