Fertility Questionnaire: {her}strategies

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for visiting herstrategies.com. Any feedback is greatly appreciated.

Email *

NAME: *

PHONE: *

AGE: *

SEX: *

Female

Male

Other:

RELATIONSHIP STATUS: (single, engaged, living with a partner, exclusive relationship, open relationship, married, etc.)

FAMILY: Did you give birth to any children? If yes, age(s) and natural vs fertility treatments?

Q1: Have you ever started fertility treatments or froze your eggs? If yes, when (age), how many times, reasons?

Q2: Is having a family someday part of your goals?

Yes, as soon as possible

Not sure

Someday, but not now

Probably not

I don’t know

Clear selection

Q3: Is this the first time you’ve heard of egg freezing? If not, how did you hear about it?

Q4: What type of birth control do you use?

Pills

IUD

Ring

Implant

Patch

Shot

Not on birth control

Clear selection

Q5: Have you ever had a fertility appointment or purchased AMH testing via at-home kit or clinic? If yes, what did you have done, the amount spent, and results?

Option 1

Clear selection

Q6: Are you planning to freeze your eggs? If yes, do you have a timeline when (age) or how many times you would like to freeze?

Q7: How often do you exercise?

Never

Occasionally

Few Times Per Month

Few Times Per Week

Every Day

Other:

Clear selection

Q8: On a scale of 1-10, how serious are you about freezing your eggs? (10 = most serious | 1 = not serious) Any specific barriers, concerns, fears, or hesitations keeping you from moving forward?

Q9: Have you ever attended an egg freezing event or a fertility seminar? Were all your questions and concerns answered?

Q10: Do you want more information about reproductive health, fertility, or egg freezing? If yes, what information would you like?

Q11: Anything else you’d like to suggest or share?

Thank you so much for your time! You're the best!

We truly appreciate your candid answers and will be in touch immediately help assist you with your fertility goals.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms