Connecticut Fertility Centers - Reproductive Medicine Associates of Connecticut

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

Under the Direction of Richard T. Scott, Jr., M.D., FACOG, HCLD, Practice Director
	Fairfield County Norwalk and Danbury Offices Joshua Hurwitz, M.D. Mark P. Leondires, M.D. Spencer Richlin, M.D. Directions	Westchester County John J. Stangel, M.D. 70 Maple Avenue Rye, NY