First Name *

Last Name *

Email *

Phone *

Let's begin with some basic details.

Your answers will help us better understand your unique situation and needs.

What is your age? *

Under 35

35 - 39

40+

Which of the following best describes you? *

Which of the following best describes you?

If applicable, what is your partner's age? *

Under 35

35 - 39

40+

N/A

How long have you been trying to grow your family? *

Less than 6 months

6 months to 1 year

Over 1 year

Have you been pregnant before? *

Yes, successfully carried to term

Yes, but resulted in miscarriage

No, never been pregnant

N/A

If applicable, has your partner ever contributed to a pregnancy that resulted in a child? *

Yes

N/A

Let's talk about your cycle.

These questions help us assess how your menstrual and ovulation patterns might impact fertility.

How regular are your menstrual cycles? *

Regular (every 25 - 35 days)

Irregular (shorter than 25 days or longer than 35 days)

I don't have periods

Do you track ovulation? *

Yes

N/A

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

Painful periods (cramps that require medication or disrupt daily life)

Very heavy bleeding

Spotting between periods

None of the above

N/A

Your medical history matters.

Understanding your health and any existing conditions gives us a clearer picture of potential factors affecting your fertility.

Do you have any of the following conditions? (Select all that apply) *

Polycystic ovary syndrome (PCOS)

Endometriosis

Uterine fibroids

Thyroid issues (hyperthyroidism or hypothyroidism)

Pelvic inflammatory disease (PID)

Diabetes

None of the above

Other

Have you undergone any surgeries or treatments involving your reproductive system?

Yes

Do you have a family history of infertility or related conditions? *

Yes

Unsure

Your partner's health is important, too.

If applicable, answering these questions will provide additional insight into potential contributing factors.

Does your partner have any known health issues that may affect fertility? *

Low sperm count or motility

History of testicular injury or surgery

None of the above

Unsure

N/A

Has your partner ever undergone a semen analysis? *

Yes (normal results)

No (abnormal results)

N/A