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SCD Study Questionnaire

Please complete the survey below.

Thank you for your time and participation.

Response was added on 06/10/2023 1:53pm.

Name: Veronica Meza

Date of Birth: 06-10-2023

Race: Black or African American

American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other (please specify)
Declines to state

Gynecology History - Menstrual

What age were you when you had your first menses? 11

How frequent is your menstrual cycle? mensual

Normally, how many days does your menstrual period 3-6

last?

When was the first day of your last menstrual period? 06-09-2023

Are you currently using birth control? Yes

No

Have you had fertility testing and/or fertility Yes

treatment before? No

If yes, what was the infertility diagnosis, what Ovulation induction

treatment? Intrauterine insemination (IUI)
(Select all that apply) IVF
Donor egg, sperm, or embryo

What year did you receive each treatment? 2022

Obstetric History
How many pregnancies have you had? 1

Year and Outcome for each pregnancy? 2018 Aborto espontaneo

Have any of your children been diagnosed with Sickle n/a

Cell Disease or Sickle Cell Trait?

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Sickle Cell Disease History

If you have Sickle Cell Disease (SCD):

Genetic diagnosis: N/A No lo se

When diagnosed:
__________________________________

How frequently have you been admitted to hospitals due

to SCD: __________________________________

Any surgeries due to SCD? Yes

No

Any stem cell transplant or chemotherapy for SCD? Yes

No

Are you on hydroxyurea? Yes

No

How frequently have you received blood transfusions?

__________________________________

How frequently have you received exchange transfusion?

__________________________________

If known, what is your baseline Hemoglobin S level?

__________________________________
(grams per deciliter (g/dl))

If you have sickle cell trait:

Genetic diagnosis: N/A No lo se

When diagnosed:
__________________________________

Any medical problems associated with it:

__________________________________________

Other Medical/Surgical History

Any other significant medical or surgical history?
Amigdalectomía de anginas
Cirugía De Extirpación De La Vesícula Biliar -
Colecistectomía de vesicular
Legrado uterino x hiperplasia endometrial
Cirugía de Corrección de vista con técnica Laser
sik. miopía y astigmatismo.
histeroscopia canulación tubárica selectiva.

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What medications do you take regularly? Lavotiroxine de 25 mg.

Venelafaxine 75 mg
Magnesium, Omega3, Acido folico, Vitamina D3,
Calcio, Q10 encima.

Family History
Does anyone in the family have the diagnosis of Sickle Yes
Cell disease? No
Unknown

Do you smoke cigarettes or use tobacco products in Yes

other forms such as chewing tobacco or vape? No

Do you drink alcohol (beer and wine included)? Yes

No

Do you use recreational drugs or prescribed Yes

medications recreationally? No

06/10/2023 1:54pm projectredcap.org