737 lines
32 KiB
HTML
737 lines
32 KiB
HTML
<!DOCTYPE html>
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<html lang='en'>
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<head>
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<meta charset='utf-8'>
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<meta name='viewport' content='width=device-width'>
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<meta name='description' content='Trans Healthcare Survey Research Website'>
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<link rel='stylesheet' href='style.css'>
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<script src="https://code.jquery.com/jquery-3.7.1.slim.min.js" integrity="sha256-kmHvs0B+OpCW5GVHUNjv9rOmY0IvSIRcf7zGUDTDQM8=" crossorigin="anonymous"></script>
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<script src='script.js'></script>
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<link rel='icon' href='logo.webp'>
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<title>HRTimelines — Form</title>
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</head>
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<body>
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<script>0</script>
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<main>
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<header>
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<div>
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<a href='https://hrtimelines.com'><img src='logo.webp' alt='logo' width='50rem' height='50rem'></a>
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<h1><a href='https://hrtimelines.com'>HRTimelines</a></h1>
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</div>
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<div id='nav'>
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<img id='hamburger' src='hamburger.svg' alt='nav' width='30rem' height='30rem'>
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<nav>
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<a href='https://hrtimelines.com'>Home</a>
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<a href='https://hrtimelines.com/about'>About</a>
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<a href='https://hrtimelines.com/future'>Future Plans</a>
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<a href='https://hrtimelines.com/contact'>Contact</a>
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<a href='https://hrtimelines.com/form'>Form</a>
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</nav>
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</div>
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</header>
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<section>
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<p>The following survey inquires about the type and physical effects of the HRT you use. Responses will be used to draw conclusions about the physical effects of HRT and to possibly correlate the timeline of effects with age, ethnicity, types of medications, medication dosage, the use of other medications, or medical conditions.</p>
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<p>Data is encrypted and stored in the eastern United States. We do not collect identifying information (such as name or email). Data is retained for future HRTimelines projects, but will not be shared outside of the research team or for any other research or commercial purposes.</p>
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<p>The survey takes around ten minutes to complete, and you must be eighteen years of age to participate in our research. For some questions, exact dates are helpful, but a best guess is acceptable. The form will not save your responses over different sessions; it is recommended that you fill the form in one sitting.</p>
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</section>
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<form action='/form' method='post' enctype='multipart/form-data'>
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<section>
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<h1>Consent</h1><p></p>
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<input type='checkbox' id='consent-age' class='con' required>
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<label for='consent-age'>I am eighteen years of age and currently taking hormone replacement therapy (HRT).</label>
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<br>
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<input type='checkbox' id='consent-data' class='con' required>
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<label for='consent-data'>I have read the above information. I agree to participate in this survey and agree to have my data retained for research purposes as described above.</label>
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</section>
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<section class='all'>
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<h1>Demographics</h1><p></p>
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<label for='dob'>What is your date of birth?</label>
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<input type='date' id='dob' name='entry.birthdate'>
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<br>
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<label for='country'>What is your primary country of residence?</label>
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<select id='country' name='entry.country'>
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<option value=""></option>
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<option value="Afghanistan">Afghanistan</option>
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<option value="Åland Islands">Åland Islands</option>
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<option value="Albania">Albania</option>
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<option value="Algeria">Algeria</option>
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<option value="American Samoa">American Samoa</option>
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<option value="Andorra">Andorra</option>
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<option value="Angola">Angola</option>
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<option value="Anguilla">Anguilla</option>
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<option value="Antarctica">Antarctica</option>
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<option value="Antigua and Barbuda">Antigua and Barbuda</option>
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<option value="Argentina">Argentina</option>
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<option value="Armenia">Armenia</option>
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<option value="Aruba">Aruba</option>
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<option value="Australia">Australia</option>
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<option value="Austria">Austria</option>
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<option value="Azerbaijan">Azerbaijan</option>
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<option value="Bahamas">Bahamas</option>
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<option value="Bahrain">Bahrain</option>
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<option value="Bangladesh">Bangladesh</option>
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<option value="Barbados">Barbados</option>
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<option value="Belarus">Belarus</option>
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<option value="Belgium">Belgium</option>
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<option value="Belize">Belize</option>
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<option value="Benin">Benin</option>
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<option value="Bermuda">Bermuda</option>
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<option value="Bhutan">Bhutan</option>
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<option value="Bolivia (Plurinational State of)">Bolivia (Plurinational State of)</option>
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<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
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<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
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<option value="Botswana">Botswana</option>
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<option value="Bouvet Island">Bouvet Island</option>
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<option value="Brazil">Brazil</option>
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<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
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<option value="Brunei Darussalam">Brunei Darussalam</option>
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<option value="Bulgaria">Bulgaria</option>
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<option value="Burkina Faso">Burkina Faso</option>
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<option value="Burundi">Burundi</option>
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<option value="Cabo Verde">Cabo Verde</option>
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<option value="Cambodia">Cambodia</option>
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<option value="Cameroon">Cameroon</option>
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<option value="Canada">Canada</option>
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<option value="Cayman Islands">Cayman Islands</option>
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<option value="Central African Republic">Central African Republic</option>
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<option value="Chad">Chad</option>
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<option value="Chile">Chile</option>
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<option value="China">China</option>
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<option value="Christmas Island">Christmas Island</option>
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<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
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<option value="Colombia">Colombia</option>
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<option value="Comoros">Comoros</option>
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<option value="Congo">Congo</option>
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<option value="Congo (Democratic Republic of the)">Congo (Democratic Republic of the)</option>
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<option value="Cook Islands">Cook Islands</option>
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<option value="Costa Rica">Costa Rica</option>
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<option value="Côte d'Ivoire">Côte d'Ivoire</option>
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<option value="Croatia">Croatia</option>
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<option value="Cuba">Cuba</option>
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<option value="Curaçao">Curaçao</option>
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<option value="Cyprus">Cyprus</option>
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<option value="Czech Republic">Czech Republic</option>
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<option value="Denmark">Denmark</option>
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<option value="Djibouti">Djibouti</option>
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<option value="Dominica">Dominica</option>
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<option value="Dominican Republic">Dominican Republic</option>
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<option value="Ecuador">Ecuador</option>
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<option value="Egypt">Egypt</option>
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<option value="El Salvador">El Salvador</option>
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<option value="Equatorial Guinea">Equatorial Guinea</option>
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<option value="Eritrea">Eritrea</option>
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<option value="Estonia">Estonia</option>
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<option value="Ethiopia">Ethiopia</option>
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<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
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<option value="Faroe Islands">Faroe Islands</option>
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<option value="Fiji">Fiji</option>
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<option value="Finland">Finland</option>
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<option value="France">France</option>
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<option value="French Guiana">French Guiana</option>
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<option value="French Polynesia">French Polynesia</option>
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<option value="French Southern Territories">French Southern Territories</option>
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<option value="Gabon">Gabon</option>
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<option value="Gambia">Gambia</option>
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<option value="Georgia">Georgia</option>
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<option value="Germany">Germany</option>
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<option value="Ghana">Ghana</option>
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<option value="Gibraltar">Gibraltar</option>
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<option value="Greece">Greece</option>
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<option value="Greenland">Greenland</option>
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<option value="Grenada">Grenada</option>
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<option value="Guadeloupe">Guadeloupe</option>
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<option value="Guam">Guam</option>
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<option value="Guatemala">Guatemala</option>
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<option value="Guernsey">Guernsey</option>
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<option value="Guinea">Guinea</option>
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<option value="Guinea-Bissau">Guinea-Bissau</option>
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<option value="Guyana">Guyana</option>
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<option value="Haiti">Haiti</option>
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<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
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<option value="Holy See">Holy See</option>
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<option value="Honduras">Honduras</option>
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<option value="Hong Kong">Hong Kong</option>
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<option value="Hungary">Hungary</option>
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<option value="Iceland">Iceland</option>
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<option value="India">India</option>
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<option value="Indonesia">Indonesia</option>
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<option value="Iran (Islamic Republic of)">Iran (Islamic Republic of)</option>
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<option value="Iraq">Iraq</option>
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<option value="Ireland">Ireland</option>
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<option value="Isle of Man">Isle of Man</option>
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<option value="Israel">Israel</option>
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<option value="Italy">Italy</option>
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<option value="Jamaica">Jamaica</option>
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<option value="Japan">Japan</option>
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<option value="Jersey">Jersey</option>
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<option value="Jordan">Jordan</option>
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<option value="Kazakhstan">Kazakhstan</option>
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<option value="Kenya">Kenya</option>
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<option value="Kiribati">Kiribati</option>
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<option value="Korea (Democratic People's Republic of)">Korea (Democratic People's Republic of)</option>
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<option value="Korea (Republic of)">Korea (Republic of)</option>
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<option value="Kuwait">Kuwait</option>
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<option value="Kyrgyzstan">Kyrgyzstan</option>
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<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
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<option value="Latvia">Latvia</option>
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<option value="Lebanon">Lebanon</option>
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<option value="Lesotho">Lesotho</option>
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<option value="Liberia">Liberia</option>
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<option value="Libya">Libya</option>
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<option value="Liechtenstein">Liechtenstein</option>
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<option value="Lithuania">Lithuania</option>
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<option value="Luxembourg">Luxembourg</option>
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<option value="Macao">Macao</option>
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<option value="Macedonia">Macedonia</option>
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<option value="Madagascar">Madagascar</option>
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<option value="Malawi">Malawi</option>
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<option value="Malaysia">Malaysia</option>
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<option value="Maldives">Maldives</option>
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<option value="Mali">Mali</option>
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<option value="Malta">Malta</option>
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<option value="Marshall Islands">Marshall Islands</option>
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<option value="Martinique">Martinique</option>
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<option value="Mauritania">Mauritania</option>
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<option value="Mauritius">Mauritius</option>
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<option value="Mayotte">Mayotte</option>
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<option value="Mexico">Mexico</option>
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<option value="Micronesia (Federated States of)">Micronesia (Federated States of)</option>
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<option value="Moldova (Republic of)">Moldova (Republic of)</option>
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<option value="Monaco">Monaco</option>
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<option value="Mongolia">Mongolia</option>
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<option value="Montenegro">Montenegro</option>
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<option value="Montserrat">Montserrat</option>
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<option value="Morocco">Morocco</option>
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<option value="Mozambique">Mozambique</option>
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<option value="Myanmar">Myanmar</option>
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<option value="Namibia">Namibia</option>
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<option value="Nauru">Nauru</option>
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<option value="Nepal">Nepal</option>
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<option value="Netherlands">Netherlands</option>
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<option value="New Caledonia">New Caledonia</option>
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<option value="New Zealand">New Zealand</option>
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<option value="Nicaragua">Nicaragua</option>
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<option value="Niger">Niger</option>
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<option value="Nigeria">Nigeria</option>
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<option value="Niue">Niue</option>
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<option value="Norfolk Island">Norfolk Island</option>
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<option value="Northern Mariana Islands">Northern Mariana Islands</option>
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<option value="Norway">Norway</option>
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<option value="Oman">Oman</option>
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<option value="Pakistan">Pakistan</option>
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<option value="Palau">Palau</option>
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<option value="Palestine, State of">Palestine, State of</option>
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<option value="Panama">Panama</option>
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<option value="Papua New Guinea">Papua New Guinea</option>
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<option value="Paraguay">Paraguay</option>
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<option value="Peru">Peru</option>
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<option value="Philippines">Philippines</option>
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<option value="Pitcairn">Pitcairn</option>
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<option value="Poland">Poland</option>
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<option value="Portugal">Portugal</option>
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<option value="Puerto Rico">Puerto Rico</option>
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<option value="Qatar">Qatar</option>
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<option value="Republic of Kosovo">Republic of Kosovo</option>
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<option value="Réunion">Réunion</option>
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<option value="Romania">Romania</option>
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<option value="Russian Federation">Russian Federation</option>
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<option value="Rwanda">Rwanda</option>
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<option value="Saint Barthélemy">Saint Barthélemy</option>
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<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
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<option value="Saint Lucia">Saint Lucia</option>
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<option value="Saint Martin (French part)">Saint Martin (French part)</option>
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<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
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<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
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<option value="Samoa">Samoa</option>
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<option value="San Marino">San Marino</option>
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<option value="Sao Tome and Principe">Sao Tome and Principe</option>
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<option value="Saudi Arabia">Saudi Arabia</option>
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<option value="Senegal">Senegal</option>
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<option value="Serbia">Serbia</option>
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<option value="Seychelles">Seychelles</option>
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<option value="Sierra Leone">Sierra Leone</option>
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<option value="Singapore">Singapore</option>
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<option value="Sint Maarten (Dutch part)">Sint Maarten (Dutch part)</option>
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<option value="Slovakia">Slovakia</option>
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<option value="Slovenia">Slovenia</option>
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<option value="Solomon Islands">Solomon Islands</option>
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<option value="Somalia">Somalia</option>
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<option value="South Africa">South Africa</option>
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<option value="South Sudan">South Sudan</option>
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<option value="Spain">Spain</option>
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<option value="Sri Lanka">Sri Lanka</option>
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<option value="Sudan">Sudan</option>
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<option value="Suriname">Suriname</option>
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<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
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<option value="Swaziland">Swaziland</option>
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<option value="Sweden">Sweden</option>
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<option value="Switzerland">Switzerland</option>
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<option value="Syrian Arab Republic">Syrian Arab Republic</option>
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<option value="Taiwan">Taiwan</option>
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<option value="Tajikistan">Tajikistan</option>
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<option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
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<option value="Thailand">Thailand</option>
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<option value="Timor-Leste">Timor-Leste</option>
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<option value="Togo">Togo</option>
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<option value="Tokelau">Tokelau</option>
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<option value="Tonga">Tonga</option>
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<option value="Trinidad and Tobago">Trinidad and Tobago</option>
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<option value="Tunisia">Tunisia</option>
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<option value="Turkey">Turkey</option>
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<option value="Turkmenistan">Turkmenistan</option>
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<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
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<option value="Tuvalu">Tuvalu</option>
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<option value="Uganda">Uganda</option>
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<option value="Ukraine">Ukraine</option>
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<option value="United Arab Emirates">United Arab Emirates</option>
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<option value="United Kingdom">United Kingdom</option>
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<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
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<option value="United States of America">United States of America</option>
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<option value="Uruguay">Uruguay</option>
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<option value="Uzbekistan">Uzbekistan</option>
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<option value="Vanuatu">Vanuatu</option>
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<option value="Venezuela (Bolivarian Republic of)">Venezuela (Bolivarian Republic of)</option>
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<option value="Viet Nam">Viet Nam</option>
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<option value="Virgin Islands (British)">Virgin Islands (British)</option>
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<option value="Virgin Islands (U.S.)">Virgin Islands (U.S.)</option>
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<option value="Wallis and Futuna">Wallis and Futuna</option>
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<option value="Western Sahara">Western Sahara</option>
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<option value="Yemen">Yemen</option>
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<option value="Zambia">Zambia</option>
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<option value="Zimbabwe">Zimbabwe</option>
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</select>
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<p>How would you label your gender? Select all that apply.</p>
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<input type='checkbox' id='g1' name='gender.male'>
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<label for='g1'>Male</label>
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<br>
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<input type='checkbox' id='g2' name='gender.female'>
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<label for='g2'>Female</label>
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<br>
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<input type='checkbox' id='g3' name='gender.genderfluid'>
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<label for='g3'>Genderfluid</label>
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<br>
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<input type='checkbox' id='g4' name='gender.genderqueer'>
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<label for='g4'>Genderqueer</label>
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<br>
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<input type='checkbox' id='g5' name='gender.non_binary'>
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<label for='g5'>Non-binary</label>
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<br>
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<input type='checkbox' id='g6' name='gender.agender'>
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<label for='g6'>Agender</label>
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<br>
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<input type='checkbox' id='g7' name='gender.demigender'>
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<label for='g7'>Demigender</label>
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<br>
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<input type='checkbox' id='g8' name='gender.questioning'>
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<label for='g8'>Questioning</label>
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<br>
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<input type='checkbox' id='g9' name='gender.other'>
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<label for='g9'>Other</label>
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<p>How would you label your ethnicity? Select all that apply.</p>
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<input type='checkbox' id='e1' name='ethnicity.east_asian'>
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<label for='e1'>East Asian</label>
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<br>
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<input type='checkbox' id='e2' name='ethnicity.african_american'>
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<label for='e2'>Black or African-American</label>
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<br>
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<input type='checkbox' id='e3' name='ethnicity.hispanic'>
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<label for='e3'>Hispanic, Latino, or Spanish origin</label>
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<br>
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<input type='checkbox' id='e4' name='ethnicity.middle_eastern_north_african'>
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<label for='e4'>Middle Eastern or North African</label>
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<br>
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<input type='checkbox' id='e5' name='ethnicity.native_american'>
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<label for='e5'>Native American or Alaska Native</label>
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<br>
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<input type='checkbox' id='e6' name='ethnicity.pacific_islander'>
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<label for='e6'>Native Hawaiian or other Pacific Islander</label>
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<br>
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<input type='checkbox' id='e7' name='ethnicity.south_asian'>
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<label for='e7'>South Asian</label>
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<br>
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<input type='checkbox' id='e8' name='ethnicity.south_east_asian'>
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<label for='e8'>South East Asian</label>
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<br>
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<input type='checkbox' id='e9' name='ethnicity.subsaharan_african'>
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<label for='e9'>Sub-Saharan African</label>
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<br>
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<input type='checkbox' id='e10' name='ethnicity.white'>
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<label for='e10'>White or European origin</label>
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<br>
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<input type='checkbox' id='e11' name='ethnicity.other'>
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<label for='e11'>Other</label>
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<p>Which type of hormone replacement therapy do you use?</p>
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<input type='radio' id='t1' name='hrt' value='Masculinizing' required>
|
|
<label for='t1'>Masculinizing</label>
|
|
<br>
|
|
<input type='radio' id='t2' name='hrt' value='Feminizing' required>
|
|
<label for='t2'>Feminizing</label>
|
|
</section>
|
|
<section class='all some'>
|
|
<h1 class='masc'>Masculinizing</h1>
|
|
<h1 class='fem'>Feminizing</h1>
|
|
<p>Please input your medication history according to the format seen in the first table below. If you take injections, please specify the volume and concentration in the amount column and specify whether you take intramuscular or subcutaneous injections in the method column. For each change in dosage, please add a new entry. You do not need to fill in a reason for termination for a change in dosage.</p>
|
|
<div class='medication'>
|
|
<div>
|
|
<label for='md5'>Start: </label>
|
|
<input id='md5' name='meds[0].start' type='date'>
|
|
<br>
|
|
<label for='md7'>End: </label>
|
|
<input id='md7' name='meds[0].end' type='date'>
|
|
<br>
|
|
<label for='md6'>Ongoing: </label>
|
|
<input id='md6' name='meds[0].frequency' type='checkbox'>
|
|
<br>
|
|
<label for='md1'>Medication: </label>
|
|
<br>
|
|
<input id='md1' name='meds[0].med' placeholder='eg. cyproterone acetate' size='20'>
|
|
<br>
|
|
<label for='md2'>Method: </label>
|
|
<br>
|
|
<input id='md2' name='meds[0].method' placeholder='eg. topical gel' size='20'>
|
|
<br>
|
|
<label for='md3'>Amount: </label>
|
|
<br>
|
|
<input id='md3' name='meds[0].amount' placeholder='eg. 0.5mL at 100mg/mL' size='20'>
|
|
<br>
|
|
<label for='md4'>Frequency: </label>
|
|
<br>
|
|
<input id='md4' name='meds[0].frequency' placeholder='eg. bidaily' size='20'>
|
|
<br>
|
|
<label for='md8'>Reason for Termination: </label>
|
|
<br>
|
|
<input id='md8' name='meds[0].stop_reason' placeholder='eg. headaches' size='20'>
|
|
<br>
|
|
</div>
|
|
</div>
|
|
<button style='margin-top: 1em;' type='button' onclick='row()'>Add Medication</button>
|
|
<p></p>
|
|
<h2>General Effects</h2>
|
|
<p>Please check any of these possible effects you have experienced while taking hormone replacement therapy.</p>
|
|
<div class='masc'>
|
|
<input type='checkbox' id='me1' name='masc.deeper_voice'>
|
|
<label for='me1'>Deeper voice</label>
|
|
<br>
|
|
<input type='checkbox' id='me2' name='masc.cessation_of_menstruation'>
|
|
<label for='me2'>Cessation of menstruation</label>
|
|
<br>
|
|
<input type='checkbox' id='me3' name='masc.facial_body_hair_growth'>
|
|
<label for='me3'>Facial and/or body hair growth</label>
|
|
<br>
|
|
<input type='checkbox' id='me4' name='masc.thicker_skin'>
|
|
<label for='me4'>Thicker skin</label>
|
|
<br>
|
|
<input type='checkbox' id='me5' name='masc.weight_gain'>
|
|
<label for='me5'>Weight gain</label>
|
|
<br>
|
|
<input type='checkbox' id='me6' name='masc.acne_oily_skin'>
|
|
<label for='me6'>More acne or more oily skin</label>
|
|
<br>
|
|
<input type='checkbox' id='me7' name='masc.male_pattern_baldness'>
|
|
<label for='me7'>Male pattern baldness</label>
|
|
<br>
|
|
<input type='checkbox' id='me8' name='masc.sleep_apnea'>
|
|
<label for='me8'>Sleep apnea</label>
|
|
<br>
|
|
<input type='checkbox' id='me9' name='masc.rise_in_cholesterol'>
|
|
<label for='me9'>Rise in cholesterol</label>
|
|
<br>
|
|
<input type='checkbox' id='me10' name='masc.high_blood_pressure'>
|
|
<label for='me10'>High blood pressure</label>
|
|
<br>
|
|
<input type='checkbox' id='me11' name='masc.polycythemia'>
|
|
<label for='me11'>Polycythemia (excess red blood cell production)</label>
|
|
<br>
|
|
<input type='checkbox' id='me12' name='masc.pelvic_bone_structure'>
|
|
<label for='me12'>Changes in pelvic bone structure</label>
|
|
<br>
|
|
<input type='checkbox' id='me13' name='masc.cramps'>
|
|
<label for='me13'>Cramps, potentially related to testosterone administration cycle</label>
|
|
<br>
|
|
<input type='checkbox' id='me14' name='masc.body_odour'>
|
|
<label for='me14'>Changes in body odour</label>
|
|
<br>
|
|
<input type='checkbox' id='me15' name='masc.fat_redistribution'>
|
|
<label for='me15'>Fat redistribution</label>
|
|
<br>
|
|
<input type='checkbox' id='me16' name='masc.increased_appetite'>
|
|
<label for='me16'>Increased appetite</label>
|
|
<br>
|
|
<input type='checkbox' id='me17' name='masc.decreased_appetite'>
|
|
<label for='me17'>Decreased appetite</label>
|
|
<br>
|
|
<input type='checkbox' id='me18' name='masc.dulled_taste_smell'>
|
|
<label for='me18'>Dulled sense of taste or smell</label>
|
|
<br>
|
|
<input type='checkbox' id='me19' name='masc.increased_irritability'>
|
|
<label for='me19'>Increased irritability</label>
|
|
<br>
|
|
<input type='checkbox' id='me20' name='masc.increased_perspiration'>
|
|
<label for='me20'>Increase in perspiration</label>
|
|
<br>
|
|
<input type='checkbox' id='me21' name='masc.decreased_perspiration'>
|
|
<label for='me21'>Decrease in perspiration</label>
|
|
<br>
|
|
<input type='checkbox' id='me22' name='masc.stronger_nails'>
|
|
<label for='me22'>Thicker or stronger nails</label>
|
|
<br>
|
|
<input type='checkbox' id='me23' name='masc.increased_muscle_mass'>
|
|
<label for='me23'>Increased muscle mass</label>
|
|
<br>
|
|
<input type='checkbox' id='me24' name='masc.face'>
|
|
<label for='me24'>Facial feature changes</label>
|
|
<br>
|
|
<input type='checkbox' id='me25' name='masc.increased_drug_tolerance'>
|
|
<label for='me25'>Increased tolerance for caffeine, alcohol, or psychotropics</label>
|
|
<br>
|
|
<input type='checkbox' id='me26' name='masc.decreased_drug_tolerance'>
|
|
<label for='me26'>Reduced tolerance for caffeine, alcohol, or psychotropics</label>
|
|
<br>
|
|
<input type='checkbox' id='me27' name='masc.improved_sleep'>
|
|
<label for='me27'>Improved sleep</label>
|
|
<br>
|
|
<input type='checkbox' id='me28' name='masc.worsened_sleep'>
|
|
<label for='me28'>Worsened sleep</label>
|
|
<br>
|
|
<input type='checkbox' id='me29' name='masc.improved_smell'>
|
|
<label for='me29'>Improved sense of smell</label>
|
|
<br>
|
|
<input type='checkbox' id='me30' name='masc.worsened_smell'>
|
|
<label for='me30'>Worsened sense of smell</label>
|
|
<br>
|
|
<input type='checkbox' id='me31' name='masc.feeling_warmer'>
|
|
<label for='me31'>Feeling warmer</label>
|
|
<br>
|
|
<input type='checkbox' id='me32' name='masc.feeling_colder'>
|
|
<label for='me32'>Feeling colder</label>
|
|
<br>
|
|
<input type='checkbox' id='me33' name='masc.sex_orientation'>
|
|
<label for='me33'>Changes in sexual orientation</label>
|
|
<p>Please mention if you have experienced any other changes, specifically non-sexual and not related to genitalia, than those listed above and/or further explain the effects you have experienced below.</p>
|
|
<textarea rows='6' cols='80' name='masc.other'></textarea>
|
|
<p></p>
|
|
</div>
|
|
<div class='fem'>
|
|
<input type='checkbox' id='fe1' name='fem.softer_skin'>
|
|
<label for='fe1'>Skin softening</label>
|
|
<br>
|
|
<input type='checkbox' id='fe2' name='fem.less_oily_skin'>
|
|
<label for='fe2'>Less oily skin</label>
|
|
<br>
|
|
<input type='checkbox' id='fe3' name='fem.increased_flexibility'>
|
|
<label for='fe3'>Increased flexibility</label>
|
|
<br>
|
|
<input type='checkbox' id='fe4' name='fem.slimmer_hands_wrists'>
|
|
<label for='fe4'>Slimmer hands and wrists</label>
|
|
<br>
|
|
<input type='checkbox' id='fe5' name='fem.smaller_feet'>
|
|
<label for='fe5'>Smaller feet</label>
|
|
<br>
|
|
<input type='checkbox' id='fe6' name='fem.thinner_softer_fingernails'>
|
|
<label for='fe6'>Thinner or softer fingernails</label>
|
|
<br>
|
|
<input type='checkbox' id='fe7' name='fem.reduced_body_hair'>
|
|
<label for='fe7'>Reduced body hair</label>
|
|
<br>
|
|
<input type='checkbox' id='fe8' name='fem.feeling_warmer'>
|
|
<label for='fe8'>Feeling warmer</label>
|
|
<br>
|
|
<input type='checkbox' id='fe9' name='fem.feeling_colder'>
|
|
<label for='fe9'>Feeling colder</label>
|
|
<br>
|
|
<input type='checkbox' id='fe10' name='fem.increased_perspiration'>
|
|
<label for='fe10'>Increased perspiration</label>
|
|
<br>
|
|
<input type='checkbox' id='fe11' name='fem.decreased_perspiration'>
|
|
<label for='fe11'>Decreased perspiration</label>
|
|
<br>
|
|
<input type='checkbox' id='fe12' name='fem.body_odour'>
|
|
<label for='fe12'>Changes in body odour</label>
|
|
<br>
|
|
<input type='checkbox' id='fe13' name='fem.fat_redistribution'>
|
|
<label for='fe13'>Fat redistribution</label>
|
|
<br>
|
|
<input type='checkbox' id='fe14' name='fem.breast_growth'>
|
|
<label for='fe14'>Breast growth</label>
|
|
<br>
|
|
<input type='checkbox' id='fe15' name='fem.reduced_muscle_mass'>
|
|
<label for='fe15'>Reduced muscle mass</label>
|
|
<br>
|
|
<input type='checkbox' id='fe16' name='fem.face'>
|
|
<label for='fe16'>Changes in facial features or face shape</label>
|
|
<br>
|
|
<input type='checkbox' id='fe17' name='fem.hairline'>
|
|
<label for='fe17'>Changes in hairline</label>
|
|
<br>
|
|
<input type='checkbox' id='fe18' name='fem.increased_drug_tolerance'>
|
|
<label for='fe18'>Increased tolerance to caffeine, alcohol, or psychotropics</label>
|
|
<br>
|
|
<input type='checkbox' id='fe19' name='fem.reduced_drug_tolerance'>
|
|
<label for='fe19'>Reduced tolerance to caffeine, alcohol, or psychotropics</label>
|
|
<br>
|
|
<input type='checkbox' id='fe20' name='fem.sex_orientation'>
|
|
<label for='fe20'>Changes in sexual orientation</label>
|
|
<br>
|
|
<input type='checkbox' id='fe21' name='fem.increased_emotional_sensitivity'>
|
|
<label for='fe21'>Increased emotional capacity or sensitivity</label>
|
|
<br>
|
|
<input type='checkbox' id='fe22' name='fem.increased_appetite'>
|
|
<label for='fe22'>Increase in appetite</label>
|
|
<br>
|
|
<input type='checkbox' id='fe23' name='fem.decreased_appetite'>
|
|
<label for='fe23'>Decrease in appetite</label>
|
|
<br>
|
|
<input type='checkbox' id='fe24' name='fem.improved_sleep'>
|
|
<label for='fe24'>Improved sleep</label>
|
|
<br>
|
|
<input type='checkbox' id='fe25' name='fem.worsened_sleep'>
|
|
<label for='fe25'>Worsened sleep</label>
|
|
<br>
|
|
<input type='checkbox' id='fe26' name='fem.improved_smell'>
|
|
<label for='fe26'>Improved sense of smell</label>
|
|
<br>
|
|
<input type='checkbox' id='fe27' name='fem.worsened_smell'>
|
|
<label for='fe27'>Worsened sense of smell</label>
|
|
<br>
|
|
<input type='checkbox' id='fe28' name='fem.taste'>
|
|
<label for='fe28'>Changes in taste</label>
|
|
<p>Please mention if you have experienced any other changes, specifically non-sexual and not related to genitalia, than those listed above and/or further explain the effects you have experienced below.</p>
|
|
<textarea rows='6' cols='80' name='fem.other'></textarea>
|
|
<p></p>
|
|
</div>
|
|
<div class='fem'>
|
|
<h2>Cyclical Effects</h2>
|
|
<p>Please check any of these possible effects you have experienced while taking hormone replacement therapy.</p>
|
|
<input type='checkbox' id='fc1' name='fem.cramping'>
|
|
<label for='fc1'>Cramping in intestine or abdomen</label>
|
|
<br>
|
|
<input type='checkbox' id='fc2' name='fem.bloating'>
|
|
<label for='fc2'>Bloating or increased water retention</label>
|
|
<br>
|
|
<input type='checkbox' id='fc3' name='fem.gas'>
|
|
<label for='fc3'>Gas or other intestinal issues</label>
|
|
<br>
|
|
<input type='checkbox' id='fc4' name='fem.unstable_emotions'>
|
|
<label for='fc4'>Emotional instability (mood swings, heightened depression, increased irritability, etc)</label>
|
|
<br>
|
|
<input type='checkbox' id='fc5' name='fem.pains'>
|
|
<label for='fc5'>Muscle or joint aches and pains</label>
|
|
<br>
|
|
<input type='checkbox' id='fc6' name='fem.breast_tenderness'>
|
|
<label for='fc6'>Breast engorgement or nipple tenderness</label>
|
|
<br>
|
|
<input type='checkbox' id='fc7' name='fem.acne'>
|
|
<label for='fc7'>Acne</label>
|
|
<br>
|
|
<input type='checkbox' id='fc8' name='fem.fatigue'>
|
|
<label for='fc8'>Fatigue</label>
|
|
<br>
|
|
<input type='checkbox' id='fc9' name='fem.appetite_cravings'>
|
|
<label for='fc9'>Appetite changes or spontaneous cravings</label>
|
|
<br>
|
|
<input type='checkbox' id='fc10' name='fem.migraines'>
|
|
<label for='fc10'>Migraines</label>
|
|
<p>Please mention if you have experienced any other changes, specifically cyclical, than those listed above and/or further explain the effects you have experienced below.</p>
|
|
<textarea rows='6' cols='80' name='fem.cycle'></textarea>
|
|
<p></p>
|
|
</div>
|
|
<h2>Sexual Effects</h2>
|
|
<p>The following effects pertain to sexuality and genitalia. If you are comfortable answering these questions, please check the following box.</p>
|
|
<input type='checkbox' id='sex' name='sex'>
|
|
<label for='sex'>I am comfortable and willing to answer questions related to my sexuality and genitalia.</label>
|
|
<div class='hide'>
|
|
<p>Please check any of these possible effects you have experienced while taking hormone replacement therapy.</p>
|
|
<div class='masc'>
|
|
<input type='checkbox' id='ms1' name='mascsex.clitoral_growth'>
|
|
<label for='ms1'>Clitorial growth</label>
|
|
<br>
|
|
<input type='checkbox' id='ms2' name='mascsex.vaginal_atrophy'>
|
|
<label for='ms2'>Vaginal atrophy</label>
|
|
<br>
|
|
<input type='checkbox' id='ms3' name='mascsex.vaginal_dryness'>
|
|
<label for='ms3'>Vaginal dryness</label>
|
|
<br>
|
|
<input type='checkbox' id='ms4' name='mascsex.genital_moisture_odour'>
|
|
<label for='ms4'>Changes in moisture and odour of genitalia</label>
|
|
<br>
|
|
<input type='checkbox' id='ms5' name='mascsex.increased_libido'>
|
|
<label for='ms5'>Increased libido (higher sex drive)</label>
|
|
<br>
|
|
<input type='checkbox' id='ms6' name='mascsex.decreased_libido'>
|
|
<label for='ms6'>Decreased libido (lower sex drive)</label>
|
|
<br>
|
|
<input type='checkbox' id='ms7' name='mascsex.orgasm'>
|
|
<label for='ms7'>Change in orgasm</label>
|
|
<br>
|
|
<input type='checkbox' id='ms8' name='mascsex.vaginal_discharge'>
|
|
<label for='ms8'>Change in vaginal discharge</label>
|
|
<br>
|
|
<input type='checkbox' id='ms9' name='mascsex.genital_sensitivity'>
|
|
<label for='ms9'>Change in genital sensitivity and/or response</label>
|
|
<p>Please mention if you have experienced any other changes, specifically sexual or related to genitalia, than those listed above and/or further explain the effects you have experienced below.</p>
|
|
<textarea rows='6' cols='80' name='mascsex.other'></textarea>
|
|
<p></p>
|
|
</div>
|
|
<div class='fem'>
|
|
<input type='checkbox' id='fs1' name='femsex.increased_genital_sensitivity'>
|
|
<label for='fs1'>Increased genital sensitivity</label>
|
|
<br>
|
|
<input type='checkbox' id='fs2' name='femsex.genital_moisture_odour'>
|
|
<label for='fs2'>Changes in moisture and odour of genitalia</label>
|
|
<br>
|
|
<input type='checkbox' id='fs3' name='femsex.genital_color_texture'>
|
|
<label for='fs3'>Changes in colour or texture of genitalia</label>
|
|
<br>
|
|
<input type='checkbox' id='fs4' name='femsex.fewer_erections'>
|
|
<label for='fs4'>Fewer erections</label>
|
|
<br>
|
|
<input type='checkbox' id='fs5' name='femsex.clear_ejaculate'>
|
|
<label for='fs5'>Clear ejaculate</label>
|
|
<br>
|
|
<input type='checkbox' id='fs6' name='femsex.testicular_atrophy'>
|
|
<label for='fs6'>Testicular atrophy</label>
|
|
<br>
|
|
<input type='checkbox' id='fs7' name='femsex.genital_response'>
|
|
<label for='fs7'>Increased arousing response to genital touch</label>
|
|
<br>
|
|
<input type='checkbox' id='fs8' name='femsex.orgasm'>
|
|
<label for='fs8'>Changes in orgasm</label>
|
|
<br>
|
|
<input type='checkbox' id='fs9' name='femsex.increased_libido'>
|
|
<label for='fs9'>Increased libido</label>
|
|
<br>
|
|
<input type='checkbox' id='fs10' name='femsex.decreased_libido'>
|
|
<label for='fs10'>Reduced libido</label>
|
|
<p>Please mention if you have experienced any other changes, specifically sexual or related to genitalia, than those listed above and/or further explain the effects you have experienced below.</p>
|
|
<textarea rows='6' cols='80' name='femsex.other'></textarea>
|
|
<p></p>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
<section class='all some'>
|
|
<h1>General</h1>
|
|
<p>Are you taking or have you taken medications not classified as a part of hormone replacement therapy which may affect, cause, or interfere with any of the effects listed above?</p>
|
|
<textarea rows='6' cols='80' name='entry.medication'></textarea>
|
|
<p>Do you have any medical conditions which may affect, cause, or interfere with any of the effects listed above?</p>
|
|
<textarea rows='6' cols='80' name='entry.conditions'></textarea>
|
|
<br>
|
|
<br>
|
|
<input type='checkbox' id='btst' name='entry.blood-test'>
|
|
<label for='btst'>I have gotten a blood test within the last year</label>
|
|
</section>
|
|
<section class='all some'>
|
|
<h1>Final Thoughts</h1>
|
|
<p>How did you hear about this survey?</p>
|
|
<textarea rows='6' cols='80' name='entry.heard'></textarea>
|
|
<p>Is there anything related to your hormone replacement therapy that you would like us to know?</p>
|
|
<textarea rows='6' cols='80' name='entry.other'></textarea>
|
|
<p>Do you have any other feedback for HRTimelines?</p>
|
|
<textarea rows='6' cols='80' name='entry.feedback'></textarea>
|
|
<br>
|
|
<br>
|
|
<input type='submit' value='Submit'>
|
|
</section>
|
|
</main>
|
|
</body>
|
|
</html>
|