Full Name

Email

Date of Birth (YYYY-MM-DD)

Mailing Address

Phone

1. We would like to know a little bit about you, and where you are at in your fertility journey. We also want to ensure that this group is a good fit for you.

2. Do you, or your partner/spouse have any medical conditions (especially those that are related to fertility problems)?

3. What is your current plan to create your family (e.g., natural conception, use of medication, eastern medicine – acupuncture/naturopathy, IUI, IVF, donation, etc.)?

4. Have you ever experienced miscarriage or loss?
YesNo

5. Do you have any living children?
YesNo

6. How are your feelings about holistic approaches to fertility?
I am all over itCautious, but curious

7. What would you like to gain out of this group (hopes, expectations)?

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