Miscarriage and Stillbirth Questionaire

Miscarriage Questionnaire
I am doing a study into the alternative / non-medical explanation to miscarriages.

Please fill out the following questions to the best of your ability.

Noa Gal Efron, M.S.W.
1) E-mail*
Less than a monthLess than a year1 - 2 yearsMore than 2 years
3) How old were you at the time of this miscarriage?*
4) In which week did you miscarry?
Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
GuiltlyRejectedFailedNone of the aboveOther
AlwaysOftenSometimesNever
Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
Positive Life ChangesNegative Life ChangesA bit of bothUncertain
YesNo
Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
Less than half a yearHalf a year to 1 year1 to 2 years2 to 5 yearsNeverOther
8c) Would you be willing to expand on this?
9) Is there anything else you would like to share about your miscarriage?
AcceptingUncertainDid not accept
11) Do you believe there is an additional explanation to the miscarriage?*
YesNo
12a) If not, why not?
YesNo
- 13a) Full Name*
  
  First NameLast Name
- YesNo
- 13c) Country
- 14) What is your current age?*
- 15) How many miscarriages have you had in total?*
- YesNoOther
- Should be Empty:

Miscarriage Questionnaire