HERstory

Thank you for sharing your story and being part of HG progress. By entering your information and allowing the HER Foundation to share your story, we are able to educate others on the need for improved care, grant funding for expanded research, and reach more people by putting a real story to the diagnosis of Hyperemesis Gravidarum or HG.

You must agree to the Media Policy at the end in order for us to use your story.

Note: By filling out this survey, you are granting HER permission to use your story for any HG-related purpose. You may choose if you would like your name and details such as losses to be withheld for privacy. Do not include other personal details you do not want public.

1. About You:

First Name *This question is required.

Last Name *This question is required.

Title

Employer/Company

Main Address

Apt/Suite/Office

City

State

Zip

Country

Personal Email *This question is required. This question requires a valid email address.

Phone Number

Mobile Phone

Profession/Affiliation (e.g. teacher, nurse, SAHM, blogger, Professor of chemistry at UCLA)

5. What languages other than English do you speak/write fluently:

8. Year, Name(s) and location* of hospital where you delivered:
*city/state (include country if outside the US)
Example: 2014, Providence, Portland, OR

9. Name(s) of your OB, perinatologist or other pregnancy specialist you saw:

10. Share your story (up to 1000 words):

11. Your key highlights and quotes you would like to share (100 word max) *This question is required.

15. Tell us about the complication(s) you experienced as a result of HG and how it impacted you and your family BOTH during pregnancy and after.

15. What were your 2-3 biggest challenges or needs during your pregnancy? *This question is required.

16. What would you like to tell others about HG and its aftermath?

18. How did the HER Foundation most help or make a difference in your pregnancy?

19. What do you tell others about the HER Foundation and why they should support the work HER does?

21. Please provide your phone number so we can contact you if we have a local media outlet. *This question is required.

Mobile Phone

21. Anything else you would like to share about your pregnancy, your health, your recovery, the HER Foundation, HG, or your health care team?

22. What type of volunteer work, advocacy, or other activities have you done for the cause/HG progress?

23. Any photos, creative content, or video you would like to share? For larger video, use WeTransfer and email us the link.

File: {{filename}} delete

24. Paste a link(s) to your blog or story online. (Your URL must be public for us to access it.) By sharing this link, you agree we may use this content as part of your story.