Full Name
*
First Name
Last Name
Contact Telephone
(###)
###
####
Email
*
Country of Residence
Date of Birth
MM
DD
YYYY
What is your current treatment status?
I am preparing for fertility treatment
I am currently in fertility treatment
How are you mostly feeling about trying to conceive via IVF?
Excited / Positive
Well prepared
Unprepared
Unclear or confused about the process
Worried / Stressed
I don’t know
If you haven’t yet started IVF, when do you plan to begin?
Within next 0-3 months
Within 4-6 months
Within 6-12 months
If you haven’t started, have you enlisted with a Fertility Doctor and clinic yet?
If you have already started treatment, for how long?
Less than 2 months
3 - 6 months
6-12 months
1-2 years
More than 2 years
If you have already started treatment, how many cycles have you completed?
Who is with you on your fertility journey?
My male partner
My female partner
I am single
Is there anyone else in your life who you consider to be a good support / will play a significant part in your IVF experience?
Have you been diagnosed with any of the following reproductive health conditions?
Have you ever been pregnant?
Yes I already have children
Yes, I have experienced pregnancy loss
Yes, I have experienced loss of born child
No
Are you currently using..?
Own eggs
Donor eggs
Who’s sperm are you currently / do you plan on using?
Partner’s sperm
Known sperm (e.g. friend)
Donor sperm from a sperm bank
Do you smoke or vape?
How much alcohol do you drink per week? (1 unit = 1 glass of wine/beer or 1 30ml shot of spirit)
0 units
1-2 units
More than 6 units
How many hours do you exercise per week?
0
1-2
3-4
5-10
More than 10 hours
How would you describe the intensity of your exercise?
Light
Moderate
Intense
In the past month, how often have you felt high stress and / or depression?
Never
Occasionally
Often
Very often
How many hours do you sleep per night, generally?
4-5
5-6
6-7
7-8
9-10
Have you made any adjustments and /or introduced anything new in preparation to conceive?
If you have a partner, have they made any adjustments or introduced anything new in preparation to conceive?
How would you rate your level of stress in relation to work and personal life?
Low
Moderate
High
Fluctuates
How well do you manage stress?
Very well
Well
Not very well
Badly
To what extent do you feel affected by your hormones during your menstrual cycle?
Greatly
Moderately
Not at all
Which of the following concerns you about fertility treatment (tick all that apply):
Please feel free to add any further information in the space below.
