Fertility Survey

As a visitor to our site, we'd like to learn more about you - anonymously, of course. Please take a minute to fill out this simple, confidential interactive survey. The information you provide can help us make improvements to our Center and the services offered, assess our patient population and be responsive to patient needs. Thank you for taking the time to help us out!

 
1. Are you a female or a male?
   female
 male

 
2. What is your age?
   under 20
 21-25
   26-30
 31-35
   36-40
  
   over 40
  

 
3. When did you begin to realize you had problems with fertility?
   less than 1 year ago
 1-2 years ago
   2-3 years ago
 more than 3 years ago

 
4. Have you seen an ob/gyn or other physician up to now for your care?
   ob/gyn internist
   primary care
      physician
 other, please specify

 
5. If you are female, who is your ob/gyn?
   

 
6. Have you been working with your ob/gyn to resolve your fertility problems?
   yes
 no

 
7. If yes, for how long?
   less than 1 year
 1-2 years
   2-3 years
 less than 3 years

 
8. What kind of information has your ob/gyn provided?

 
9. Have you been satisfied with the care from your ob/gyn?
   yes
 no

 
10. Have you been taking any medications?
   Clomid
 Pergonal
   Repronex
 Humegon
   Follistim
 Metrodin
   Fertinex
    		 other, please specify

 
11. How do you obtain information about infertility? Check all that apply.
   From my ob/gyn
 From RESOLVE
   From the Internet
 Relative/Friend
   Books
     		 other, please specify

 
12. Are you a member of RESOLVE?
   yes
 no

 
13. Do you plan to join RESOLVE?
   yes
 no
If yes, submit your survey by clicking below, then visit RESOLVE's Web site at www.resolve.org

 

Frequently Asked Questions

Fertility Survey

Books We Recommend

Fertility Myths

Message Board

Glossary of Terms

CMEs for Referring MDs

 

 

 

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The Center For Advanced Reproductive Services
Where giving you care means giving you hopeSM
John Nulsen, M.D. | Donald Maier, M.D. | Claudio Benadiva, M.D. | David Schmidt, M.D.
August Olivar, M.D. | Lawrence Engmann, M.D., M.R.C.O.G. | Andrea DiLuigi, M.D.

Farmington Office
Dowling South Building
263 Farmington Ave
Farmington, CT 06030
(860) 679-4580
 Hamden Office
2080 Whitney Avenue
Suite 250
Hamden, CT 06518
(203) 230-4400
 Hartford Office
100 Retreat Avenue
Suite 900
Hartford, CT 06106
(860) 525-8283

www.uconnfertility.com
Part of the University of Connecticut Health Center
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