Pre-Screen Survey Questions

First Name*

Last Name*

Have you been diagnosed with PCOS?*

Are you seeking immediate fertility?*

Are you between 18 and 40 years of age?*

Do you have a BMI of less than 40?*
Find your BMI

Have you had ovulation induction treatment such as letrozole or clomiphene citrate without successful results, or are you contraindicated for or declined such treatment?*

If you are a potential candidate for the REBALANCE Study, do you grant May Health or its affiliates permission to contact you for further information?*

Phone

State

Zip Code

How did you hear about May Health?
(Check all that apply.)

Internet Search

My OB/Gyn

My Fertility Specialist

Facebook

Instagram

Patient Advocacy Group

A Friend

Other

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