User Interviews Sign-up Form

Thank you for your interest in participating in the ongoing Samphire user research! Please fill in the form below to register your interest and we will get back to you with the next steps! The information you provide in this form is completely confidential and your data will not be shared with anyone outside the Samphire Neuroscience team. If you have any further questions about the process please contact us at justyna@samphireneuro.com.

What is your name?

What is your email address?

We need this information in order to provide to contact you with the next steps and schedule the interview.

How old are you ?

Which of the below statements describes you best.

A

I regularly experience physical or mental symptoms associated with dysmenorrhea (period pain) and PMS (abdominal cramps, headaches, low mood, mood swings, fatigue, irritability, cravings, etc.)

B

I suspect I have PMDD (Pre-menstrual dysphoric disorder) or have been diagnosed with it by a medical practitioner

C

I suspect I have endometriosis or have been diagnosed with it by a medical practitioner

D

None of the above

Which of the below statements describe(s) you best.

I am young professional (people between 20 and 40 who are employed in a profession or white-collar occupation)

I am a full-time masters or doctoral student

I am a mother

I am a professional or semi-professional athlete

None of the above