| Check the response which reflects how you usually feel (i.e., not just how you might feel on day 28 of your cycle) |
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| Regarding my level of optimism about my chances of getting pregnant soon: |
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I am very optimistic that I will get pregnant soon |
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I am cautiously optimistic |
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I have moments when I feel optimistic but they are getting less frequent |
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I feel very discouraged and sometimes think I am just going through the motions |
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| When a friend or family member tells me that they are pregnant, I: |
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genuinely feel happy for them |
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am happy for them, but feel resentful it wasn't me |
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feel sad and angry |
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am devastated |
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| My sex life: |
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is the same or better than before infertility |
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is ok, but it clearly has been affected by the infertility |
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is clearly suffering and I wonder if it will ever be good again |
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is nonexistent - I or we just don't feel like making love anymore |
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| I find that I feel sad: |
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about as often as before |
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more often that I would like but it feels manageable |
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it is intense when I get bad news and/or when I get my period |
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most of or all the time |
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| My relationships with my friends: |
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is as good as it has always been |
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is ok as long as they don't talk about their children or pregnancies |
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is ok as long as I avoid certain insensitive people |
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I try to avoid almost all of them |
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| My current level of awareness of my menstrual cycle: |
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is the same; I have a vague idea where I am in my cycle |
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I know where I am in my cycle when I am receiving treatment |
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I am consistently careful to know the exact days of the important phases |
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I know exactly what day it is every day |
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| My family: |
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has been supportive and carefully involved |
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does not know anything about my infertility |
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some members of my family know, but they are not supportive |
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I told them, but they either refuse to ask about it or continue to make hurtful comments |
| |
| My anxiety level: |
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is the same as before infertility |
|
spikes during certain times of my cycle |
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is elevated throughout my cycle, but I feel at least somewhat ok |
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is sky-high much of the time |
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| My internet time spent on infertility: |
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is nonexistent |
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I research things on the web, but do so carefully |
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I regularly lurk in at least one chat room |
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I research everything I can and check in with at least one chat room regularly |
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| My infertility: |
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is an unpleasant, but controlled part of my life |
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takes a lot more of my mental energy than I would like |
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is permeating most aspects of my life |
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has totally taken over how I feel almost if not all the time |
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| I am: |
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Male |
|
Female |
| |
|
| I am:
years old. |
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| Name:
|
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| Would you like to be contacted? If so, how... |
|
Please phone me to discuss infertility related stress reduction programs.
Phone:
|
|
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Please e-mail me information about infertility related stress reduction programs.
* Email:
|
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I would prefer not to be contacted |
| |
| The following questions are OPTIONAL. The responses we receive will be complied anonymously and analyzed as a group. We are hoping to improve the way in which fertility treatment is delivered by gaining insight into the changes in patients' stress levels during different phases of treatment. To skip these questions, simply scroll to the bottom of the page and click "submit," and you will receive the score to your stress test. |
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| Have you initiated fertility treatment?
Yes
No |
| |
| |
If "no," how long have you been trying to get pregnant on your own? |
| |
6 to 12 months
1 to 2 years
2 years or more |
| |
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If "yes" which of the following types of Medical Professionals have you discussed your case with (check all that apply)? |
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OBGYN
Primary Health Care Physician
Reproductive Endocrinologist
Psychologist / Psychiatrist / Social Worker specializing in infertility |
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| How long did you try to get pregnant on your own prior to initiating treatment? |
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6 to 12 months |
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1 to 2 years |
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2 years or more |
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| Where are you in your treatment? Check all that apply: |
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Undergoing or completed diagnostic work-up |
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Undergoing or completed treatment cycles of IUI with Clomid |
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Undergoing or completed treatment cycles of IUI with FSH |
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Undergoing or completed treatment cycles of IVF |
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Undergoing or completed treatment cycles IVF with Donor Sperm |
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Undergoing or completed treatment cycles IVF with Donor Egg |
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Undergoing or completed treatment cycles with Gestational Carrier |
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Other |
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| What is the one thing that you feel is contributing to your level of stress the most? |
|
| |
|
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| Are you a Pacific Fertility Center patient?
Yes
No |
| |
| Home Town Zip Code:
|
