Fertility Quality of Life Questionnaire (2008)

For each question, kindly check (tick the box) for the response that most closely reflects how you think and feel.

Relate your answers to your current thoughts and feelings. Some questions may relate to your private life, but they are necessary to adequately measure all aspects of your life.

Please complete the items marked with an asterisk (*) only if you have a partner.

First Name

 

Date of Birth

 

Last Name

 

MRN
(RVH blue card number)

 

For each question, check the response that is closest to your current thoughts and feelings

 

Very Poor

Poor

Nor good
nor poor

Good

Very Good
A How would you rate your health?  

 

Very Dissatisfied

Dissatisfied

Neither Satisfied Nor Dissatisfied

Satisfied

Very Satisfied
B Are you satisfied with your quality of life?  

 

Completely

A Great Deal

Moderately

Not Much

Not At All
Q1 Are your attention and concentration impaired by thoughts of infertility?

 

Q2 Do you think you cannot move ahead with other life goals and plans because of fertility problems?

 

Q3 Do you feel drained or worn out because of fertility problems?

 

 

 

 
Q4 Do you feel able to cope with your fertility problems?

 

 

Very Dissatisfied

Dissatisfied

Neither Satisfied Nor Dissatisfied

Satisfied

Very Satisfied
Q5 Are you satisfied with the support you receive from friends with regard to your fertility problems?  
*Q6 Are you satisfied with your sexual relationship even though you have fertility problems?

  

 

Always

Very Often

Quite Often

Seldom

Never
Q7 Do your fertility problems cause feelings of jealousy and resentment?

 

Q8 Do you experience grief and/or feelings of loss about not being able to have a child (or more children)?  
Q9 Do you fluctuate between hope and despair because of fertility problems?  
Q10 Are you socially isolated because of fertility problems?  
*Q11 Are you and your partner affectionate with each other even though you have fertility problems?  
Q12 Do your fertility problems interfere with your day-to-day work or obligations?  
Q13 Do you feel uncomfortable attending social situations like holidays and celebrations because of your fertility problems?  
Q14 Do you feel your family can understand what you are going through?  

 

An Extreme Amount

Very Much

A Moderate Amount

A Little

Not At All
*Q15 Have fertility problems strengthened your commitment to your partner?  
Q16 Do you feel sad and depressed about your fertility problems?  
Q17 Do your fertility problems make you inferior to people with children?  
Q18 Are you bothered by fatigue because of fertility problems?  
*Q19 Have fertility problems had a negative impact on your relationship with your partner?  
*Q20 Do you find it difficult to talk to your partner about your feelings related to infertility?  
*Q21 Are you content with your relationship even though you have fertility problems?  
Q22 Do you feel social pressure on you to have (or have more) children?  
Q23 Do your fertility problems make you angry?  
Q24 Do you feel pain and physical discomfort because of your fertility problems?  

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Optional Treatment Module

Have you started fertility treatment (this includes any medical consultation or intervention)? If Yes, then please respond to the following questions.

For each question, kindly check (tick the box) for the response that most closely reflects how you think and feel. Relate your answers to your current thoughts and feelings. Some questions may relate to your private life, but they are necessary to adequately measure all aspects of your life.

For each question, check the response that is closest to your current thoughts and feelings

 

Always

Very Often

Quite often

Seldom

Never

T1

 Does infertility treatment negatively affect your mood?

 

 T2

 Are the fertility medical services you would like available to you?  

 

 

An Extreme Amount

Very Much

A Moderate Amount

A Little

Not At All
 T3 How complicated is dealing with the procedure and/ or administration of medication for your infertility treatment(s)?  
 T4 Are you bothered by the effect of treatment on your daily or work related activities?  
 T5 Do you feel the fertility staff understand what you are going through?  
 T6 Are you bothered by the physical side effects of fertility medications and treatment?  
 

Very Dissatisfied

Dissatisfied

Neither Satisfied nor Dissatisfied

Satisfied

Very Satisfied
 T7 Are you satisfied with the quality of services available to you to address your emotional needs?  
 T8 How would you rate the surgery and/or medical treatment(s) you have received?

 

 T9 How would you rate the quality of information you received about medication, surgery and/or medical treatment?  
 T10 Are you satisfied with your interactions with fertility medical staff?