| 1 |
Please rate your overall level of interest in fertility issues on a scale of 1 to 10. (1 = no interest, 10 = very interested) |
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| 2 |
In your opinion, what is your overall level of knowledge of fertility issues? Please rate on a scale of 1 to 10. (1 = I’m not very knowledgeable, 10 = I am very knowledgeable) |
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| 3 |
How does your level of knowledge compare to that of your spouse/partner? |
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More knowledgeable
Equally knowledgeable
Less Knowledgeable
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| 4 |
The following questions are about your attitudes and beliefs about various fertility issues. Please answer the following questions True or False: |
| a. |
I believe that infertility is a significant medical condition. |
True
False |
| b. |
I believe that infertility is a common medical condition. |
True
False |
| c. |
I believe that women suffer from fertility problems more often than men. |
True
False |
| d. |
I believe that insurance companies should cover the costs of infertility treatment. |
True
False |
| e. |
I think that infertility treatments are unnatural. |
True
False |
| f. |
I think that if a couple can’t get pregnant naturally, they should adopt or live child-free rather than undergo advanced infertility treatments like IVF. |
True
False |
| 5 |
If you and your spouse/partner were trying to conceive without success, at what point would you suspect that there might be a problem? |
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| 6 |
What actions would you be willing to take if you were concerned about your own fertility? (Check all that apply) |
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| 7 |
At what point would you contact a health care professional regarding this issue? |
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| 8 |
What type of health care professional would you most likely contact first? |
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Family Practitioner
Internist
OB/GYN
Urologist
Fertility Specialist |
| 9 |
If you and your spouse/partner were trying to conceive and were having difficulty what would be your role in seeking information on infertility? |
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Neither I nor my spouse/partner would seek information
I would not be active in seeking information about infertility but my spouse/partner would be.
I would seek information but not as actively as my spouse/partner
I would be just as active about seeking information on infertility as my partner
I would be more active in seeking information on infertility than my partner
I would be actively seeking information on infertility, my partner would not be |
| 10 |
What would be your role in seeking treatment with a fertility specialist? |
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Neither I nor my spouse/partner would seek information
I would not be active in seeking information about infertility but my spouse/partner would be.
I would seek information but not as actively as my spouse/partner
I would be just as active about seeking information on infertility as my partner
I would be more active in seeking information on infertility than my partner
I would be actively seeking information on infertility, my partner would not be |
| 11 |
If a fertility specialist recommended that your spouse/ partner undergo a procedure such as in-vitro fertilization or drug therapy in order to conceive, what would be your greatest concern? (Please rank each with 1 being your greatest concern, 2 being your second greatest concern, etc.) |
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Cost
Risk of procedure/side effects
Success rates
Emotional stress
Other |
| 12 |
Please tell us a little about yourself: |
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