NAME: *

PHONE: *

AGE: *

SEX: *

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?

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?

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?

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?

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?