The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

Untitled form
Send
Untitled form
Section 1 of 1
Question
Question Type
Loading image...
a) 2-5 years
b) 6-10 years
c) 11-15 years
d) 16-20 years
e) Over 20 years
Add option
or
add "Other"
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Medical college
b) Government hospital
c) Nursing homes
d) Private practitioner
Other…
Add option
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Oral pills
b) IUD (Copper/Hormonal)
c) PP IUD
d) Injectable
e) Emergency contraception (ie, i-Pill, Unwanted 72, Preventol, etc.)
f) Male condom
g) Female condom
h) Diaphragm/cervical cap
i) Contraceptive sponge (Today, etc)
j) Sterilization (male or female)
k) Other (please specify)
l) I do not prescribe/recommend contraception to my patients.
Add option
or
add "Other"
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Most effective
b) Has very few side effects
c) Easy to administer
d) Easily available
e) Patient’s preference/choice
Other…
Add option
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Spacing of birth
b) Family completed
c) Prefer to remain childless, either short-term or permanently (ie, single sexually active persons)
Other…
Add option
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Lack of awareness/knowledge about methods of contraception
b) Trying to conceive
c) Concerned about side effects
d) Inaccurate information about reproductive/ sexual health
e) Inaccessible
f) Busy work schedules
g) Religious reasons/family pressure, etc.
Other…
Add option
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Yes
b) No
Add option
or
add "Other"
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
Yes (please specify:)
b) No
Other…
Add option
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Once
b) Rarely
c) Occasionally
d) Regularly
e) Never
Add option
or
add "Other"
Answer key
(0 points)
Loading...
Loading...
Question
Question Type
Loading image...
a) Did not have the need to prescribe
b) Don’t know about emergency contraceptive pills
c) May be contraindicated for pregnancy/cause pregnancy termination
d) Concerned about misuse
Other…
Add option
Answer key
(0 points)
Loading...
Loading...
Message for respondents
This form is no longer accepting responses
Insights
Total points distribution
Loading...
Loading responses...
1. For how long have you been practicing?
No responses yet for this question.
2. Where do you work?
No responses yet for this question.
3. Which modern methods of contraception do you prefer to prescribe/recommend to your patients? [Tick the appropriate ones]
No responses yet for this question.
4. If you prescribe/recommend contraception to your patients, what is the reason for prescribing your preferred contraception method?
No responses yet for this question.
5. In your opinion, why do couples use contraception?
No responses yet for this question.
6. In your opinion why do some couples do not go for contraception?
No responses yet for this question.
7. The government of India has added new contraceptive choices - Injectable contraceptive DMPA (Antara),Centchroman Pill (Chhaya) and Progestinonly Pill (PoP) - in the National Family Planning Programme. Are you aware of these?
No responses yet for this question.
8. Are you aware of the long-term reversible spacing methods of contraception
No responses yet for this question.
9. Have you ever prescribed/recommended emergency contraceptive pills to yourpatients?
No responses yet for this question.
10. If no, what is the reason?
No responses yet for this question.
of
10
Main menu
.