Please submit by June 15, 2012

DES ACTION USA wishes to compile information on the health experiences of women and men exposed to DES. Many conditions will NOT be related to DES exposure. However, collecting clues in this way can help us alert the scientific community to possible areas of needed research. We hope that you will help us with this project by completing the following questionnaire. Also, please forward this questionnaire link to any DES-exposed person you know:

While we prefer that individuals complete their own questionnaire, there may be situations where a relative may need to complete the survey (i.e. a parent for a young child). If you complete the survey for someone else, please make sure that person is not completing the survey as well.

* 1. Are you completing this questionnaire about:

* 2. Is the person a DES-exposed:

  Know for Sure Think So

* 3. Have you/they ever tried to obtain medical records to verify DES exposure?

* 4. Were the records received?

* 5. Date of Birth:

Month / Day / Year

* 6. Current Age

* 7. Height

* 8. Weight

* 9. Currently live in: