What is your relationship status? (Check one answer)
Which one of the following categories includes your age? (Check one answer)
Which one of the following categories includes your spouse or partner’s age? (Check one answer)
Have you experienced any of the following health problems in the past 24 months? (Select all that apply)
Has your spouse or partner experienced any of the following health problems in the past 24 months? (Select all that apply)
Which of the following best describes you and your partner’s situation with respect to trying to become pregnant during the past 24 months? (Check one answer)
If became pregnant in the past 24 months: Concerning being pregnant, please check all that apply to your situation. (Check all that apply)
If have not become pregnant but have been trying during past 24 months: How long would you say you have been trying to become pregnant and have a baby? (Check one answer)
If have tried to become pregnant for less than 12 months: Do you plan to continue trying to become pregnant for at least another six months? (Check one answer)
If became pregnant in the past 24 months: Did you (or your partner) receive fertility treatments in the past two years? (Check one answer)
If have tried to become pregnant but not successful in the past 24 months: Thinking about the past two years, which of the following best describes your and your partner’s situation with respect to using fertility treatments to become pregnant? (Check one answer)
To the best of your knowledge, is the difficulty you and your partner are having getting pregnant caused by: (Check one answer)
What types of things have you/your partner done to try to conceive or become pregnant? (Check all that apply)
If currently receiving treatment: What type of healthcare professional are you and your partner currently seeing for fertility treatments? (Check all that apply)
If seeing a fertility specialist or reproductive endocrinologist: If you and your partner could start over, would you go to a fertility specialist sooner than you did? (Check one answer)
