Miscarriages are generally a topic that people do not want to talk about or think about, and when it happens to a woman, she is left wondering whether it was her fault or something she had done. Together we can shed more light on this “taboo” topic and help inform women that they are not alone, and that what they are experiencing is common and normal.

Please fill out this short questionnaire, sharing your story will go a long way towards helping women everywhere be more informed about the miscarriage process.

Background Info

How old were you when you miscarried? *
What was the father's age?*
Was it your first pregnancy? *
Was it a single pregnancy or multiples? *
How far along in the pregnancy where you when you miscarried?*
Was there a confirmed fetal heartbeat? *
How many previous miscarriages have you had?*
Did you have an ectopic pregnancy? *

Overall Health

How would you classify your overall health during pregnancy?*
Did you have any pre-existing conditions during pregnancy? *
Did you smoke, drink, or use drugs during pregnancy? (Select all that apply)*
Were you taking any prescription drugs? If so, please list them.*

Warning Signs of Miscarriage

What signs and symptoms did you experience leading up to the miscarriage? (Select all that apply)*
Of the signs and symptoms that you experienced leading up to the miscarriage, please specify how long you experienced each symptom for. *
If you experienced symptoms not listed above, please explain what they were.*
When you noticed that you were experiencing symptoms of a miscarriage (or just knew that something wasn't right) did you seek medical help?*

During Miscarriage

When you realized that you were having a miscarriage did you seek medical help or did you chose to stay home for the miscarriage? *
If you went to the hospital, did you elect to pass it naturally, take meds to induce passing, or did you opt for surgery? *
What symptoms did you experience during the miscarriage? Please explain in as much detail as possible. There is no such thing as TMI (too much info).*

Symptoms After Miscarriage

What symptoms did you experience after the miscarriage? (Select all that apply)*
If you experienced symptoms not listed above after your miscarriage, please explain what they were.*
Of the signs and symptoms that you experienced after the miscarriage, please specify how long you experienced each symptom for.*
Please describe your feelings after the miscarriage. How long did those feelings last?*
How long did you wait to attempt getting pregnant again?*
First Name:*
Email address:*