Birth Control Survey

I am doing this survey as part of my final project for my Health Information

Management class. Birth control can be an uncomfortable topic to discuss so
thank you for participating in this survey. Please know that all answers will
remain anonymous and confidential.
1. What is your age group?
o
o
o
o
o
o

Under 18
18 25
26 35
36 45
46 - 55
Over 55

2. What is your gender?

o Female
o Male
3. What is your ethnic background?
o
o
o
o
o
o
o

African American/Black
Asian
Caucasian
Hispanic/Latino
Middle Eastern
Native American
Pacific Islander

4. What is your marital status?

o Married
o Single
5. What is your highest level of education completed?
o
o
o
o
o

High school diploma or equivalent

Associates degree
Bachelors degree
Masters degree
Other _________________

6. How often do you use birth control?

o Always
o Occasionally
o Never
7. What methods of birth control do you currently use (if any)? Check all that
apply.
o
o
o
o
o
o
o
o
o

Condom
Injections
IUD
Pill
Sterilization (Female)
Sterilization (Male)
Withdrawal
None
Other __________________

8. What do you use birth control to prevent?

o Pregnancy
o STDs
o Both
9. What factors might prevent you from using birth control? Check all that
apply.
o
o
o
o
o
o
o
o

Availability
Cost
Embarrassment
Laziness
Medical reasons
Pressure from your partner
None
Other ___________________

10. Is using birth control important to you and why? Please explain your
answer below. (For example: No, because I can not afford to buy it. OR Yes,
because I do not want children right now.)