Please complete the following medical screening questions below to determine your eligibility. Your information will not be shared with third parties and will remain private.

Please read our privacy policy for more details.

Thank you for your interest in this research study.

Please Note: You do not have to answer any particular question. However, your responses will be used to determine if you are a good match for our research study.

How did you find out about this study opportunity?

What is your name?


First	MI	Last

What is your date of birth?

dd-mm-yyyy

What is your zip or postal code?

Have you had a previous preterm delivery?

Yes No

Are you currently pregnant with one baby?

Yes No

Are you currently less than 20 weeks pregnant?

Yes No

Approximately how many weeks pregnant are you?

Have you had any progesterone hormone treatments in any form (i.e., vaginal, oral or injections with a needle) during your current pregnancy?

Yes No Unsure

Have you taken any blood thinners, in any form other than oral, during your current pregnancy?

Yes No Unsure

Have you ever been told by your doctor that you have blood clots?

Yes No Unsure

Do you currently have a surgical stitch in your cervix?

Yes No

Do you have high blood pressure that requires medication?

Yes No

Has your doctor told you that you have a seizure disorder?

Yes No Unsure

Have you participated in a research study in the last 30 days?

Yes No