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  For Jessica, lost to Cornual Ectopic pregnancy at 13 weeks, April 25, 2003
 

 

Research Questionnaire

Please fill out the following questionnaire to help us in our research.  It only takes 5-10 minutes to complete.

It is very important that everyone who has had an ectopic pregnancy fill out the following questionnaire.

This questionnaire will be used to identify problem areas in the diagnosis and care women receive during and after their ectopic pregnancy.  We all know that improvements need to made and your experiences can make that happen.

Ectopic Pregnancy Foundation will hold your personal identifying information confidential and it will not be forwarded to anyone without your consent.

Privacy Policy

Research Questionnaire Ongoing Results

 

Your Personal Information
First Name:       Last Name: 
Address:   
City:    State:    Zip/Postal Code: 
Country:    Phone Number: 
Email Address:    Date Of Birth: 
 
Ethnicity
Do You Smoke?
  Yes     How Much? 
  No      How Long?  
  Quit
Quit how much did you smoke?
How long did you smoke? 
  Hispanic or Latin
  White
  Black, African American
  Asian
  American Indian
  Other          Please Specify: 

Do you know anyone else personally who has had an ectopic pregnancy?

Have you suffered from or received treatment for any of the following conditions prior to your 1st ectopic pregnancy?

  No   Pelvic Infection
  Mother   Endometriosis
  Daughter   Had a Coil (IUD)
  Sister   Used the Mini Pill
  Other Blood Relative   Chlamydia
  Other Relative   Caesarean Section
  Friend
  Appendicitis
    Voluntary Termination
Fertility treatment, what type?
  Miscarriage
  IUI  (Intrauterine Insemination)   Abdominal Surgery
  IVF (Invitro Fertilization)   Tubal Surgery
  Fertility Treatment
  D & C
  Other    Please Specify: 
  Sterilization/Tubes Tied
 

Pregnancies

Type of Pregnancy Total Number Before 1st Ectopic Number After 1st Ectopic
Live Births
Ectopics  
Miscarriages
Still Births
Terminations
 
Please list your ectopic pregnancies in date order.
1st:  2nd:  3rd:  4th: 
 

Your first Ectopic Pregnancy experience.

If you had more than one ectopic pregnancy, please return to this page after completing and submitting this form, scroll to the bottom and click the link Additional Ectopic Pregnancies.  It is important to fill out the Additional Ectopic Pregnancy Questionnaire for each ectopic.
Date of this ectopic pregnancy: 
 
What type of ectopic pregnancy did you have?  (tubal, cornual, etc.) 
Before your first ectopic pregnancy, did you know what an ectopic pregnancy was?           Yes      No
 
What were your symptoms?
  Abdominal Pain
  Vaginal Bleeding
  Bowel Problems
  Feeling Faint
  Vomiting
  Pain in the Shoulder
  Feeling Unwell
  Fainting
  Late Period
  To have scan because of a previous ectopic pregnancy
  Scan following IVF or other infertility treatment
  Sudden Collapse
  None, Found during routine prenatal care
Please give details of any other symptoms you had:
By which healthcare professional were you first seen?

Did you know or suspect you were pregnant?

  General Practitioner   I knew I was pregnant
  Midwife   Suspected I was pregnant
  RN
  I did not know I was pregnant
  Emergency Room Doctor  
  OB/Gyn
Were you asked if you were pregnant?
  Emergency admission with collapse   Yes
  No
  Don't know Was a pregnancy test done at this time?
  Other     Please Specify 
  Yes
  No
If you knew you were pregnant did you inform anyone? Did you suspect it was an ectopic pregnancy?
  Yes
  No
  Yes
  No
What color best describes the bleeding you had? Who first suspected it was an ectopic pregnancy?
  Bright Red   General Practitioner
  Dark Red   Midwife
  Prune Juice   OB/Gyn
  Other     Please Specify    Emergency Room Doctor
  None
  Other     Please Specify 
What was your initial diagnosis? How many weeks pregnant were you?
  Ectopic Pregnancy 3      4     5     6     7     8     9
  Suspected Ectopic Pregnancy 10   11   12   13   14   15   16
  Uterus Infection
More than 16                Don't Know 
  Gastro Problems  
  Food Poisoning
How many weeks pregnant were you when your
  Appendicitis symptoms started to appear?
  Irritable Bowel Syndrome 3      4     5     6     7     8     9
  Possible Miscarriage 10   11   12   13   14   15   16
  Ovarian Cysts
More than 16                Don't Know 
  Menstrual Disturbance What tests were performed?
  Normal Pregnancy   Urine Pregnancy Test
  Treated for Miscarriage and Properly Diagnosed Later   Single Blood Pregnancy Test
  Other     Please Specify 
  Serial Blood Pregnancy Tests
Please state how many times you visited each of the   Internal Exam
following before your ectopic pregnancy was   Abdominal Ultrasound Scan
diagnosed.   Vaginal (internal) Ultrasound Scan
General Practitioner:    Other    Please Specify 
OB/Gyn: 
  None
Hospital: 
 
 

After you Were Diagnosed as Having an Ectopic Pregnancy

Was ectopic pregnancy fully explained to you after it was diagnosed? If you were given information, how was it given to you?
  Yes
  No
  Verbally
  Written
Were you given any options as to the treatment of your ectopic pregnancy?  (Not all treatments are available in every hospital.)  (You may choose more than one.) What treatment did you actually receive for your Ectopic Pregnancy?  (Not all treatments are available in every hospital.)  (You may choose more than one.)
  None   Don't Know
  Collapsed-Urgent Surgery Required Surgery
Surgery   Keyhole
  Keyhole   Abdominal Incision
  Abdominal Incision   Removal of Tube
  Removal of Tube   Did not Remove Tube
  Not Remove Tube   Removed Uterus-Hysterectomy
  Remove Uterus-Hysterectomy   Removed Ovary
  Remove Ovary   Treated with Methotrexate-Had Surgery Later
Medical Medical
  Methotrexate   Methotrexate
  Wait and See if it Would Resolve Itself
  Wait and See if it Would Resolve Itself
Did your tube rupture? Did your uterus rupture?
  Yes
  No               
  Yes
  No         
Was your tube removed? Was part or all of your uterus removed?
  No      
  Partially Removed      
  No      
  Partially Removed  
  Removed Completely      
  Don't Know      
  Removed Completely 
  Don't Know   
Which tube was affected? Was part or all of your ovary removed?
  Right             Left              Don't Know   No                                    Partially Removed
    Removed Completely        Don't Know   
Were you told what would happen to your baby? Which ovary was affected?
  Yes                                 No   Right             Left              Don't Know
Do you feel you were given an adequate explanation of the treatment you received?
What hospital were you treated at?  Please give as much information as you can; Name, Address, City, State, Zip, Phone Number, etc.
  Yes
  No   

 

After Your Treatment

Were you informed of the risks of future ectopic pregnancies? Were you advised to have an early scan when you next became pregnant to make sure your pregnancy was in the right place?
  Yes   No      Yes   No   
Did the health professional who looked after you give you information about local or national ectopic pregnancy support groups? Were you given any written information about ectopic pregnancies prior to leaving the hospital?
  Yes   No      Yes   No   
Were you given any information about the Ectopic Pregnancy Foundation? What information or literature were you given about the Ectopic Pregnancy Foundation?
  Yes   No   Website Address   Brochure
     Email   Friend
    Other      Please Specify 
   

Pregnancies You Have Had After This Ectopic

None Yes-I have conceived naturally.
  My family is complete. Number of Children: 
  Too scared to try again. Number of Miscarriages: 
  Having difficulty conceiving. Number of Ectopics: 
  Too soon after ectopic pregnancy. Yes-I have needed assisted conception (IVF, etc.)
  Number of Children: 
  Number of Miscarriages: 
  Number of Ectopics: 
Have you suffered from any medical problems since having your ectopic pregnancy that you did not have before and that you feel could be associated with your ectopic pregnancy?
  Yes
  No
If yes, please give details and treatment you received.
 

Additional comments, or information not covered during the questionnaire.

 

    

(The "Reset Button" resets the ENTIRE form.)

 
 
 
 
 
 
 
 
 
 
 

                           Additional Ectopic Pregnancies

 

 
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