Psychotherapy, Counseling & Personal Coaching

Be Part of My Research Study

Thank you for your interest in this questionnaire. I am authoring a book about the challenges of fertility, I Am More Than My Infertility: 7 Proven Steps for Reclaiming Your Life. As part of my research, I am compiling statistical data on women who have experienced difficulties or delays in trying to conceive and/or successfully maintain their pregnancy.

Your participation in this survey will be a significant contribution to the guidance and support that this book will provide to many, many women. Your answers and personal information are 100% confidential and you will not be contacted after the survey unless you voluntarily provide your email address.

Thank you in advance for your help!

1. Have you consulted a doctor or other medical specialist about your conception/pregnancy difficulties?
	YES			NO
2. Have you consulted a counselor/therapist/clergy member about your conception/pregnancy difficulties?
		Counselor
		Therapist
		Clergy Member
		Have not sought counseling
3. Have you participated in a fertility support group online?
	YES			NO
If yes, did you find this support helpful?
	YES			NO
Have you participated in a support group in person?
	YES			NO
If yes, did you find this support helpful?
	YES			NO
4. What is your present age?					-- Choose -- Younger than 18 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 30 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Older than 60
5. Before trying to become pregnant, did you anticipate you would have trouble conceiving, or successfully carrying a pregnancy?
	YES			NO
6. How old were you when it first crossed your mind that pregnancy might not occur easily?					-- Choose -- Younger than 18 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 30 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Older than 60
7. How old were you when you first started trying to conceive?					-- Choose -- Younger than 18 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 30 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Older than 60
8. How long did you try before you realized there was a problem with becoming pregnant?					-- Choose -- 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 1 Year 1-2 Years More than 2 Years
9. How long after realizing there was a problem, did you wait before consulting a physician?					-- Choose -- 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 1 Year 1-2 Years More than 2 Years
10. If you consulted a medical specialist, was he or she able to give you a specific reason or cause for your conception/pregnancy difficulties?
	YES			NO
11. Please list everything you tried because you believed it might increase your chances of becoming pregnant. (Check all that apply)
		Fertility Drugs
		IVF
		Special Diet
		Different positions during intercourse
		Herbs
		Acupuncture
		Other. Please specify:
12. Do you (or did you) have primary or secondary infertility?
		Primary
		Secondary
13. Are you undergoing (or have you undergone) IVF?
	YES			NO
If yes, how many times?					-- Choose -- 1 2 3 4 5 6 7 8 9 More than 9
If yes, did your IVF result in a pregnancy that you carried to term?
	YES			NO
14. Have you participated in fertility treatment that included third party reproduction, such as: (check all that apply)
		Known egg donors
		Anonymous egg donors
		Known sperm donors
		Anonymous sperm donors
		Previously known gestational carriers
		Legally contracted gestational carriers not previously known
		Have not tried a third party reproduction fertility treatment.
15. What is your total number of pregnancies?					-- Choose -- 0 1 2 3 4 5 6 7 8 9 More than 9
16. What is your total number of miscarriages?					-- Choose -- 0 1 2 3 4 5 6 7 8 9 More than 9
17. How many biological children do you have?					-- Choose -- 0 1 2 3 4 5 6 7 8 9 More than 9
18. Are you exploring adoption?
	YES			NO
19. How many adopted children do you have?					-- Choose -- 0 1 2 3 4 5 6 7 8 9 More than 9
20. Comments about how fertility issues have impacted your life:
21. Comments about any positive events/emotions/changes that have occurred because of your challenges with fertility issues:
22. If the authors would like to ask you additional questions, may we contact you by email?
	YES			NO
If yes, please include your email address.