My Breast Pain - Toll Free 1-888-817-9622

IS THIS STUDY RIGHT FOR ME?
If you are interested in participating in this study, please complete the information requested below and answer a few questions assessing your medical condition in order to determine your eligibility for this research study.

Please tell us how you learned about this research opportunity.

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Poster or Brochure at Doctor's Office
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My physician told me

*First Name:		Middle Initial:
*Last Name:		*Address:
*City:		*State or Province:
*Country:		*Zip/Postal Code:
*Email:		*Phone:
*Date of Birth:	(mm/dd/yyyy)	*Gender:

Do you experience six days or more of moderate or severe breast pain per cycle?
Yes No

Do you have lumpy breasts or has your physician indicated that you have fibrocystic breast tissue?
Yes No

Do you have regular menstrual cycles?
Yes No

Are you willing to keep a daily diary that will describe your breast pain for the length of this study that is about 7 months?
Yes No Unsure

Do you have a history of any of the following kinds of heart disease:
a. Thyroid related disease Yes No
b. Breast cancer Yes No

Are you nursing or attempting to become pregnant ?
Yes No