LARC Patient Education Survey: Help Us Help You!

Help US help YOU! Please take this short survey:

(Responses are completely anonymous)

Question Title

* 1. How old are you?

Under 15

15-20

21-30

31-40

Over 40

Question Title

* 2. What's your race/ethnicity? (check all that apply)

Black

White

Hispanic

Native American

Asian

Other (please specify)

Question Title

* 3. What's your zip code?

Question Title

* 4. Do you know what the IUD & birth control implant are?

Yes, I knew before reading this brochure

I had an idea about what it was, but I wasn't sure

I didn't know before, but now I do

No, I still don't know

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* 5. Has your doctor ever talked to you about your birth control options?

Yes

I don't remember

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* 6. If yes, have you discussed the IUD and implant?

Yes

I don't remember

We never talked about it

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* 7. Have you ever used an IUD or implant before?

Yes, I currently use one

Yes, I have used one in the past

I don't know

Question Title

* 8. Do you know the risks and benefits of using an IUD or implant?

Yes, I knew before reading this brochure

I had an idea about what they were, but I wasn't sure

I did not know before, but now I do

No, I still don't know

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* 9. You can get an IUD or implant if you: (check all that apply)

Are an adolescent or teenager

Are HIV-positive

Have never had a baby or have been pregnant

All of the above

None of the above

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* 10. I can get an IUD or implant in the hospital immediately after I deliver my baby.

True

False

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* 11. I should also use a condom if I have an IUD or implant to prevent sexually transmitted infections.

True

False

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* 12. Did the information in this brochure help you make a decision about your birth control choices?

Yes

I'm not sure

Thank you for completing our survey, responses will be used to inform future educational programing within District II!