Fertility Questionnaire: {her}strategies
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Email address
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Your email
NAME:
*
Your answer
PHONE:
*
Your answer
AGE:
*
Your answer
SEX:
*
Female
Male
Other:
RELATIONSHIP STATUS: (single, engaged, living with a partner, exclusive relationship, open relationship, married, etc.)
Your answer
FAMILY: Did you give birth to any children? If yes, age(s) and natural vs fertility treatments?
Your answer
Q1: Have you ever started fertility treatments or froze your eggs? If yes, when (age), how many times, reasons?
Your answer
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?
Your answer
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?
Your answer
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?
Your answer
Q9: Have you ever attended an egg freezing event or a fertility seminar? Were all your questions and concerns answered?
Your answer
Q10: Do you want more information about reproductive health, fertility, or egg freezing? If yes, what information would you like?
Your answer
Q11: Anything else you’d like to suggest or share?
Your answer
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.
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