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1 In your opinion, what is your overall knowledge of fertility issues?
Very knowledgeable
Knowledgeable
Somewhat knowledgeable
Not at all knowledgeable
2 What statement best represents you and your spouse/partner’s knowledge about infertility?
My spouse/partner and I are equally knowledgeable
I am more knowledgeable than my spouse/partner
My spouse/partner is more knowledgeable than me
I am not sure
3 The following statements are about attitudes and beliefs concerning infertility. Please answer each statement with Agree or Disagree:
a. I believe that infertility is a significant medical condition. True
False
b. Infertility is very common. True
False
c. Women suffer from fertility problems more often than men. True
False
d. Infertility treatments are too costly for me. True
False
e. I am open to exploring fertility treatments if we have trouble conceiving. True
False
f. I would consider surrogacy or adoption if we have trouble conceiving. True
False
g. I know what next steps to take and who to consult if we have trouble conceiving. True
False
4 If you and your spouse/partner were trying to conceive without success, at what point would you suspect that there might be a problem?
Less than 3 months
Between 3-6 months
Between 6-12 months
More than a year
More than 2 years
Never
5 At what point would you contact a healthcare professional if you and your spouse/partner were having trouble conceiving?
Less than 3 months
Between 3-6 months
Between 6-12 months
More than a year
More than 2 years
Never
6 What type of healthcare professional would you or your spouse/partner most likely contact first?
Family Practitioner/Primary Care Doctor
OB/GYN
Urologist
Fertility Specialist
7 What actions would you be willing to take if you were concerned about your own fertility? (Check all that apply)
a) Talk to friends and family
b) Talk to your doctor
c) Search for information online
d) Call a toll-free information line
e) Get your sperm analyzed
8 If you and your spouse/partner were trying to conceive and were having difficulty, what would be your role in seeking information on infertility?
I would be actively seeking information on infertility, my spouse/partner would not be.
I would be more active in seeking information on infertility than my spouse/partner.
I would be just as active about seeking information on infertility as my spouse/partner.
I would seek information, but not as actively as my spouse/partner.
I would not be active in seeking information about infertility but my spouse/partner would be.
Neither I nor my spouse/partner would seek information
9 What would be your role in seeking treatment with a fertility specialist?
I would be actively seeking information on infertility, my spouse/partner would not be.
I would be more active in seeking information on infertility than my spouse/partner.
I would be just as active about seeking information on infertility as my spouse/partner.
I would seek information, but not as actively as my spouse/partner.
I would not be active in seeking information about infertility but my spouse/partner would be.
Neither I nor my spouse/partner would seek information.
10 What effect has fertility issues had on your relationship? (Check all that apply)
It has had no effect on our relationship.
We only have sex with the intent to reproduce.
There is an overall drain on our emotions, adding more stress to our daily lives.
We fight a lot more.
We have learned that we handle big life decisions very differently.
We are having financial problems due to the cost of treatment.
We have learned how to become supportive of each other’s emotional needs.
We have become more open in communication.
11 While dealing with fertility issues, have you felt: (Check all that apply)
Fear
Anger
Denial
Stress
Blame
Embarrassment
Sad or Depressed
Jealousy at other people’s happy baby news
Loss of control
12 If a doctor recommended that you or your spouse/partner undergo fertility treatments in order to conceive, what would be your greatest concern, if any? (Please rank each with 1 being your greatest concern, 2 being your second greatest concern, etc.)
Cost
Risk of treatment/side effects
Success rates
Emotional stress
Other
I do not have concerns
13 Are you and your spouse/partner currently trying to conceive?
Yes
No
14 Please tell us a little about yourself:
Age:
Number of children:
Sex: Male Female
Please select one: Married Divorced Widowed
Never been married