Beta hCG Level Survey Form

This survey is being conducted in order to create a list of average hCG levels. Since people use different methods of dating pregnancy, you'll find the form has six different ways for you to report the date your hCG level was recorded. You need to fill in at least one of the six for the level to be used. For those who got pregnant after IVF, we would really appreciate having days post transfer filled in as well.

You'll also notice that we have several rows that can be filled in. This is because doctors often repeat testing early in pregnancy, especially among women who have undergone infertility treatments. Most women will only be able to fill in one or two rows, but we have included more spaces for those who continued to get tested.

Please include your e-mail address so we can verify information if needed.

If you can report on more than one pregnancy, please fill out a new form for each one (submit form and then use back in your browser to return).

Days Post  LH Surge or  hCG Trigger	Days Post  Ovulation  or Retrieval	Days Post  3-Day  Transfer	Days Post  2-Day  Transfer	Days Post  5-Day  Transfer	Weeks &  Days LMP  i.e., 5w2d	hCG  Level

Your e-mail (name@server.com):

Are you currently pregnant?    Yes      No

Has your baby been born already?    Yes       No

Is this a singleton, twin or triplet pregnancy?    Singleton       Twin      Triplet

When did you hear/see the heartbeat (LMP)?

Did this pregnancy end in miscarriage?    Yes       No

Was this an ectopic pregnancy?    Yes       No

Please add any notes you feel relevant: