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Fertility Assessment

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First Name

Last Name

Email

Country

Age

Section 1

Menstrual Cycle

How long is your typical menstrual cycle?

Less than 21 days

21–35 days

More than 35 days

My cycle is irregular

Do you often skip periods?

Yes

No

If you do skip periods, when did it first start happening?

Recently (past 6 months)

Over a year ago

It has always been irregular

Do you experience painful periods?

Mild or none

Moderate

Severe

Debilitating pain

How would you describe your period flow?

Light/Spotty

Normal

Heavy

Very heavy (changing pads/tampons every 1–2 hours)

Have you noticed bleeding or spotting between periods?

Yes

No

What’s the longest you've gone without having a period (not including pregnancy)?

Less than 2 months

2–6 months

More than 6 months

What’s the longest your period has ever lasted?

Less than 5 days

5–7 days

More than 7 days

1–3 months

Longer than 3 months

Do you experience any of the following during your period? (Select all that apply.)

Nausea

Vomiting

Diarrhea

None of the above

Have you ever taken birth control?

Yes

No

Reason for taking birth control?

To regulate my period

To prevent unwanted pregnancy

To stop long/heavy period

Other

I never took it

While on birth control, did you have regular periods?

Yes

No

I never took birth control

Section 2

Ovulation & Hormones

Do you track your ovulation?

Yes, regularly

Sometimes

No

Do you notice signs of ovulation like cervical mucus, breast tenderness, or ovulation pain?

Yes

No

Do you have facial hair, acne, or thinning hair on your scalp?

Yes

No

Section 3

Reproductive & Pregnancy History

How long have you been trying to conceive?

Less than 6 months

6–12 months

Over a year

More than 2 years

Have you ever been pregnant before?

Yes

No

What is your pregnancy history?

I have one or more children

I had an abortion

I experienced a miscarriage

I have never been pregnant

Have you taken anything to help with conception?

Yes

No

If yes, what did you take? (Select all that apply)

Clomiphene (Clomid)

Glucophage (Metformin)

Herbal remedies

Progesterone supplements

IVF (In Vitro Fertilization)

IUI (Intrauterine Insemination)

None

Do you experience lower abdominal pain?

Yes

No

Have you ever had surgery related to your uterus or ovaries?

Yes

No

Check all symptoms you experience

Mood Swings

Hot Flashes

Dryness

Dark Blood at the start or end of a cycle

Odor Issues

Clotting

Spotting/Bleeding after sex

Painful Intercourse

Low/No Sex Drive

Abnormal Vaginal Discharge

Odor

Facial Hair

Acne

Lower Back Pain

Diet & Lifestyle

Your Daily Habits

Do you follow a specific diet

Vegetarian

Vegan

Keto

Gluten-free

I eat what I want

How often do you consume fast food or takeout?

Never

Rarely (less than once a month)

Occasionally (1–3 times per month)

Frequently (1–2 times per week)

Very Often (3 or more times per week)

How often do you consume Dairy?

Never

Rarely (less than once a month)

Occasionally (1–3 times per month)

Frequently (1–2 times per week)

Very Often (3 or more times per week)

How often do you consume red meat?

Never

Rarely (less than once a month)

Occasionally (1–3 times per month)

Frequently (1–2 times per week)

Very Often (3 or more times per week)

How often do you consume chicken?

Never

Rarely (less than once a month)

Occasionally (1–3 times per month)

Frequently (1–2 times per week)

Very Often (3 or more times per week)

How often do you consume water?

Never

I could do better

A lot

Do you exercise regularly?

Yes

No

Are you. currently on any medications? If yes, please list

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