Preliminary Eligibility Questionnaire

Thank you for your interest in the Bellevue Medical Center Uterus Transplantation Clinical Research Program.
This questionnaire is intended for preliminary screening purposes only and does not determine eligibility for uterus transplantation. Final eligibility can only be established following a comprehensive medical evaluation by the Bellevue Medical Center Uterus Transplantation Team.

Question Title

1. I have read and understood the above statement and agree to proceed.

SECTION 1: CONTACT INFORMATION

Question Title

2. Full Name

Question Title

3. Country of Residence

Question Title

4. Mobile Number (including country code)

Question Title

6. Preferred Method of Contact

SECTION 2: DONOR AVAILABILITY

Question Title

7. Do you currently have a potential uterus donor willing to be evaluated?

If No:
At this stage, participation in the uterus transplantation program requires an identified potential donor. You may still submit your information, and our team will contact you to discuss your situation.
SECTION 3: RECIPIENT INFORMATION

Question Title

8. Date of Birth

Question Title

9. What best describes your condition?
(Choose all that apply)

Question Title

10. Have you been told by a physician that your ovaries are functioning normally?

Question Title

11. Have you ever undergone major abdominal surgery?
(Examples include bowel surgery, kidney surgery, major gynecological surgery, or other major abdominal procedures)

Question Title

12. Have you ever been diagnosed with cancer (malignancy)?

Question Title

13. What is your current height? (cm)

Question Title

14. What is your current weight? (kg)

Question Title

15. Have you ever been diagnosed with any of the following?
(Select all that apply)

SECTION 4: DONOR INFORMATION

Question Title

16. What is the relationship between you and the donor?

Question Title

17. Date of Birth of Potential Donor

Question Title

18. Has your donor gone through menopause?

Question Title

19. Has your donor ever been diagnosed with a uterine condition?
(Examples include fibroids, adenomyosis, uterine abnormalities, uterine surgery, or other uterine diseases.)

Question Title

20. Has your donor had at least one full-term pregnancy resulting in a live birth?

Question Title

21. Has your donor ever had a preterm delivery?

Question Title

22. How many cesarean sections has your donor had?

Question Title

23. Has your donor ever undergone major abdominal surgery?
(Examples include bowel surgery, kidney surgery, major gynecological surgery, or other major abdominal procedures.)

Question Title

24. Has your donor ever been diagnosed with cancer (malignancy)?

Question Title

25. What is your donor's current height? (cm)

Question Title

26. What is your donor's current weight? (kg)

Question Title

27. Has your donor ever been diagnosed with any of the following?
(Select all that apply)

SECTION 5: ADDITIONAL INFORMATION

Question Title

28. Is there any additional medical or personal information you would like to share with our team?

T