Pregnancy Test Questionnaire Form
Please complete this questionnaire to help us understand your recent pregnancy test experience. Do not include any sensitive or identifying information.
What is your age range?
*
Please Select
Under 18
18-24
25-34
35-44
45 or older
When did you take your most recent pregnancy test?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What type of pregnancy test did you use?
*
Home urine test
Blood test at clinic
Other
How many days after your missed period did you take the test?
*
What was the result of your most recent test?
*
Positive
Negative
Unclear/Invalid
Have you experienced any of the following symptoms recently? (Select all that apply)
Missed period
Nausea or morning sickness
Breast tenderness
Fatigue
Frequent urination
Other
If you received a negative or unclear result, did you retest?
Yes
No
Not applicable
How confident did you feel about using the pregnancy test?
1
2
3
4
5
Did you consult anyone (e.g., pharmacist, friend, online resource) before or after taking the test?
Yes, before
Yes, after
Yes, both
No
Any comments about your experience or suggestions for improvement?
Submit
Should be Empty: