The Moms-in-Waiting Project Questionnaire

The Moms-in-Waiting Project
Questionnaire

Thank you for taking a moment to share the story of your journey through infertility. I’m a mom, too, and I know how busy you are, so I really appreciate your time. Please take as much -- or as little -- space as you like to answer the questions below. You can e-mail your answers with “Moms” in the subject line or print this form and mail it to: Shelly Thacker Meinhardt, The Moms-in-Waiting Project, P.O. Box 22104, St. Paul, MN 55122. Please keep a copy for your files.

If your story is selected for inclusion in my upcoming book, I’ll need to contact you, so please provide your name, e-mail address and/or phone number. Your contact information will be kept strictly confidential. Stories featured in the book will be listed by first name and state (or country) only -- and you can choose to remain completely anonymous if you prefer.

Please note: Participants will not receive financial compensation of any kind for sharing their stories. Thank you very much for sharing your experience, wisdom, and hope with all the “moms-in-waiting” who long for a child.

Please Type or Print Clearly

Name:

Address:

City:

State/Province:

ZIP/Postal Code:

Country:

E-mail:

Phone (please indicate Work/Cell/Home):

Career/Profession (or previous field of work if you’re now a stay-at-home mom):

1. Number of years you struggled with infertility (from when you first started trying to conceive to when you became pregnant and gave birth, or adopted a child):

2. What was your infertility diagnosis? (Please mark all that apply):

	Ovulation problem
	Polycystic ovarian syndrome (PCOS)
	Progesterone problem/luteal phase defect (LPD)
	High FSH
	Premature ovarian failure (POF)
	Endometriosis
	Structural problem (i.e. uterine deformity, blocked fallopian tubes)
	Multiple miscarriages
	Male factor
	Unexplained infertility
	Secondary infertility
	Other (please specify):

3. Please briefly share the story of your infertility journey: How did your struggles begin? What highs and lows did you face along the way?

4. How did you successfully resolve your infertility? (Please mark all that apply):

	Fertility drugs (please specify):
	IUI
	IVF
	GIFT
	ZIFT
	Surgery (female)
	Surgery (male)
	Donor egg
	Donor sperm
	Donor embryo
	Gestational host or surrogate mother
	Holistic medicine (i.e. herbs, acupuncture, massage, yoga; please specify):
	Changes in diet or exercise (please specify):
	Prayer/meditation
	Adoption
	Other (please specify):

5. What do you feel were the most important steps you took toward successfully resolving your infertility?

6. What didn’t work for you? What turned out to be a waste of time or the worst advice you received?

7. If you had it to do over again, is there anything you would do differently?

8. (If you resolved your infertility through adoption, please skip to question #10.)
Was your pregnancy:
o Singleton (one baby)
o Multiple (please specify: o Twins o Triplets o Quads or more)

9. What was the experience of pregnancy like for you? Was it difficult to relax and enjoy your pregnancy? Did you have any complications? How was your labor and delivery?

10. (If you resolved your infertility through pregnancy, please skip to question #11.)
What was your adoption experience like? Were there any surprises? How did it feel to bring your child home?

11. Your age when your first baby was born/adopted:

12. Number of children and ages:

13. Imagine you’re talking with a friend who’s struggling with infertility. What are the most important words of advice you want to share with her?

14. Are there any websites, books, CDs, or videos you found helpful that you would recommend to women currently experiencing infertility?

15. Did you have any favorite inspiring quotes, sayings, songs, etc. that helped you make it through the difficult times?

16. For those struggling to conceive, becoming a mom is a dream come true—a dream that often seems out of reach. Please share what that dream-come-true feels like: What do you love most about being a mom? What does it mean to you to be a mom at last?

17. Is there anything else you'd like to add? Any other thoughts you'd like to share with the readers of this book?

Important: Terms & Conditions
By submitting this questionnaire you acknowledge and agree to the following terms and conditions: All submissions become the property of Shelly Thacker Meinhardt and will not be returned. Submissions do not guarantee publication. Submissions chosen for publication may be edited, published, or otherwise reused in any medium without payment to you of any kind. You acknowledge that names and places may be changed and that editorial changes may be made as deemed suitable by the publisher. Whether changes are made, you waive any rights of action you may have and release the publisher and Shelly Thacker Meinhardt from any and all claims arising from the publication.

Thank you very much for taking the time to share your experience. If your story is selected for inclusion in the book, I’ll contact you soon. If you have any questions, please don’t hesitate to ask: e-mail me with “Moms” in the subject line or write to Shelly Thacker Meinhardt, The Moms-in-Waiting Project, P.O. Box 22104, St. Paul, MN 55122. Click here for updates on this book.

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