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Your answers help us understand your unique journey and how we can best support you.

What is your age? *

Under 35

35 - 39

40+

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

Your Cycle

These questions help us understand menstrual and ovulation patterns.

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) *

Your Health & History

These questions help us understand factors that might affect fertility.

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

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 Lifestyle

These questions help us explore how daily habits and overall health may influence fertility.

How often do you smoke or use tobacco products? *

Daily

Occasionally

Never

How often do you consume alcohol? *

Daily

Weekly

Rarely

Never

What is your body mass index (BMI)? *

Underweight (<18.5)

Normal weight (18.5 - 24.9)

Overweight (25 - 29.9)

Obese (30+)

How would you describe your stress levels? *

Low

Moderate

High

Your Partner’s Health

If applicable, answering these questions will give extra insight into potential contributing factors.

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

Has your partner ever undergone a semen analysis? *

Yes (normal results)

Yes (abnormal results)

N/A

First Name *

Last Name *

Email *

Phone *