Intrarosa Screening Questionnaire Question Title * 1. Name OK Question Title * 2. Contact Information (this information will only be used to contact you if you qualify to participate in the study). Name State/Province Email Address Phone Number OK Question Title * 3. How old are you? OK Question Title * 4. What is your date of birth? OK Question Title * 5. What is your menopausal status? Pre-menopause Peri-menopause Post-menopause OK Question Title * 6. List ALL current medications and supplements. OK Question Title * 7. Do you have an uncontrolled metabolic or endocrine disease (including diabetes mellitus)? Yes No If yes, please explain. OK Question Title * 8. If you are using estrogen injectable drug therapy and/or progestin implant, are you willing to stop 6 months prior to screening visit? Yes No OK Question Title * 9. If you are using oral estrogen, progestin, or DHEA and/or intrauterine progestin therapy, are you willing to stop 8 weeks prior to screening visit? Yes No OK Question Title * 10. If you are using vaginal hormone products (rings, creams, gels, or tablets), transdermal estrogen alone, or estrogen/progestin products, are you willing to stop 8 weeks prior to screening visit? Yes No OK Question Title * 11. Are you currently using any androgens or anabolic steroids? Yes No If yes, please specify. OK Question Title * 12. If you are using androgens or anabolic steroids, are you willing to stop 3 months prior to the screening visit? Yes No If no, please explain. OK Question Title * 13. Do you currently have clinically significant, uncontrolled depression or confirmed history of severe psychiatric disturbance? Yes No If yes, please explain. OK Question Title * 14. Are you participating or do you plan on participating in any other clinical trials other than this trial? Yes No OK Question Title * 15. Are you currently taking or plan on taking an investigational drug 30 days prior to the screening visit and throughout the study? Yes No OK Question Title * 16. Do you have uterine fibroids? Yes No OK Question Title * 17. Have you ever been diagnosed with uterine prolapse? Yes No OK Question Title * 18. Do you suffer from a vulvar dermatologic disorder (lichen sclerosus, lichen planus, candidiaisis, lichen simplex chronicus, ect)? Yes No If yes, please explain. OK Question Title * 19. Have you chronically used narcotics and/or alcohol within the past 5 years? Yes No If yes, please explain. OK Question Title * 20. Have you used marijuana within the past 2 years? Yes No OK DONE