24-1061 Postpartum Depression (PPD)

Screening Survey

Thank you for your interest in our upcoming study. Please fill out the following preliminary questions below. Once completed, if you qualify, we will follow up with you shortly after to discuss details and scheduling. If you do not qualify, we will email you at the end of the project thanking you for your time and asking if you would be interested in future projects that you may qualify for.

If you have any questions, please contact Clinton at (224) 358-9013 or email Clinton@lagripperesearch.com

Thank you!

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* 1. Please fill out the following contact information:

First Name

Last Name

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 2. We are seeking participants for a virtual conversation and study. If you are eligible to participate in the market research, you will be invited to participate in a 60 minute interview, during which we would like to hear about your experiences with your health and treatment decisions.

This will be an interesting and interactive session, and we will be offering $125 as a compensation for your time to those people who qualify and participate in that 60 minute interview.

Rest assured that the responses that you submitted will be kept completely confidential and are only used to identify appropriate candidates for this research and coordinate interview details for those that qualify. We will comply with all applicable federal and state privacy and data protection laws, as well as all other applicable regulations when it comes to its collection, access, use, storage, disposal and disclosure of Personal Data and will not utilize your Personal Data (e.g. your name, email address, IP address, or any other identifying information) for purposes unrelated to this market research.

Based on the above, do you consent to participate in this study, if you are eligible?

Yes

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* 3. What is your age?

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* 4. Which of the following best describes your gender?

Male

Female

Prefer to self-identify:

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* 5. In which state do you currently reside?

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* 6. Are you personally, or are any of your immediate family members, employed in any of the following industries?

Marketing agency or marketing research department within a company or consulting firm

Advertising agency

Food and Restaurants

Automotive

Biotech

Pharmaceuticals

Travel/Airlines

Electronics

Hotels

Real Estate

Agricultural Services

Education

Retail

None of these

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* 7. Has a doctor ever diagnosed you as having any of the following? Select all that apply.

Postpartum depression (PPD)

High blood pressure

Diabetes

Joint pain

Gastrointestinal reflux disease (GERD)

Asthma

Endometriosis

Uterine fibroids

Urinary incontinence

Pelvic prolapse

None of the above