Fertility Acupuncture Survey

1. Fertility Acupuncture Feedback

An opportunity for you to feedback your experience of Fertility Acupuncture. Thank you! Feedback from you is so helpful for others when trying to decide whether or not to have acupuncture to help with fertility problems. It's also great to hear your views. Please be aware that your views may be shared as testimonials on my website of Facebook page 'devon fertility acupuncture'. If you wish to remain anonymous please tick 'anonymous' in question 10 on this survey. Thank you for your time.

What is your Name and How old were you when you had Acupuncture Treatment?

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* 1. What is your Name and How old were you when you had Acupuncture Treatment?

Where do you live?

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* 2. Where do you live?

City/Town:

Country:

Email Address:

Phone Number:

When you came to have Acupuncture to help with fertility was it for your first child or second or more? Was the acupuncture to support IVF / ICSI or as a stand alone treatment? Please mark the appropriate boxes.

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* 3. When you came to have Acupuncture to help with fertility was it for your first child or second or more? Was the acupuncture to support IVF / ICSI or as a stand alone treatment? Please mark the appropriate boxes.

	First IVF	Second IVF	Third IVF	ICSI	Natural Fertility
First Child	First Child First IVF	First Child Second IVF	First Child Third IVF	First Child ICSI	First Child Natural Fertility
Second Child	Second Child First IVF	Second Child Second IVF	Second Child Third IVF	Second Child ICSI	Second Child Natural Fertility
Third Child	Third Child First IVF	Third Child Second IVF	Third Child Third IVF	Third Child ICSI	Third Child Natural Fertility

Was it just you (please indicate male / female) having treatment or did your partner also have treatment? Please could you fill in who had treatment and whether or not you had Chinese Herbs as well. Please could you also fill in for how long (approximately) you each had acupuncture sessions.

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* 4. Was it just you (please indicate male / female) having treatment or did your partner also have treatment? Please could you fill in who had treatment and whether or not you had Chinese Herbs as well. Please could you also fill in for how long (approximately) you each had acupuncture sessions.

	One session only	Between two and six sessions	Between seven and twelve sessions	Between twelve and twenty four sessions	More than twenty four sessions
Acupuncture for Male only	Acupuncture for Male only One session only	Acupuncture for Male only Between two and six sessions	Acupuncture for Male only Between seven and twelve sessions	Acupuncture for Male only Between twelve and twenty four sessions	Acupuncture for Male only More than twenty four sessions
Acupuncture for Female only	Acupuncture for Female only One session only	Acupuncture for Female only Between two and six sessions	Acupuncture for Female only Between seven and twelve sessions	Acupuncture for Female only Between twelve and twenty four sessions	Acupuncture for Female only More than twenty four sessions
Acupuncture for Both Partners	Acupuncture for Both Partners One session only	Acupuncture for Both Partners Between two and six sessions	Acupuncture for Both Partners Between seven and twelve sessions	Acupuncture for Both Partners Between twelve and twenty four sessions	Acupuncture for Both Partners More than twenty four sessions
Acu & Herbs for Male only	Acu & Herbs for Male only One session only	Acu & Herbs for Male only Between two and six sessions	Acu & Herbs for Male only Between seven and twelve sessions	Acu & Herbs for Male only Between twelve and twenty four sessions	Acu & Herbs for Male only More than twenty four sessions
Acu & Herbs for Female only	Acu & Herbs for Female only One session only	Acu & Herbs for Female only Between two and six sessions	Acu & Herbs for Female only Between seven and twelve sessions	Acu & Herbs for Female only Between twelve and twenty four sessions	Acu & Herbs for Female only More than twenty four sessions
Acu & Herbs for Both Partners	Acu & Herbs for Both Partners One session only	Acu & Herbs for Both Partners Between two and six sessions	Acu & Herbs for Both Partners Between seven and twelve sessions	Acu & Herbs for Both Partners Between twelve and twenty four sessions	Acu & Herbs for Both Partners More than twenty four sessions

Please can you describe what you were looking to get out of treatment:

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* 5. Please can you describe what you were looking to get out of treatment:

How did you benefit from treatment?

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* 6. How did you benefit from treatment?

Were there any side effects that you experienced from your Acupuncture treatment or from taking the Chinese Herbs? - (side effects could be good or bad)..

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* 7. Were there any side effects that you experienced from your Acupuncture treatment or from taking the Chinese Herbs? - (side effects could be good or bad)..

How was your overall experience of Fertility Treatment affected by having Acupuncture / Taking Chinese Herbs?

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* 8. How was your overall experience of Fertility Treatment affected by having Acupuncture / Taking Chinese Herbs?

How would you describe your experience of having Acupuncture with Nicola?

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* 9. How would you describe your experience of having Acupuncture with Nicola?

Would you be happy for me to use any of your comments for promotional purposes either on the website or on my acupuncture Facebook pages as testimonials?

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* 10. Would you be happy for me to use any of your comments for promotional purposes either on the website or on my acupuncture Facebook pages as testimonials?


Yes with full name and occupation	Yes with full name and occupation	Yes with full name and occupation
Yes with first name and occupation	Yes with first name and occupation	Yes with first name and occupation
Yes with just first name	Yes with just first name	Yes with just first name
Yes with just occupation	Yes with just occupation	Yes with just occupation
Yes as anonymous	Yes as anonymous	Yes as anonymous
No, I'd rather not.	No, I'd rather not.	No, I'd rather not.

Other (please specify)