Your Fertility Assessment

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For how long have you been trying to conceive?

Less than 1 year

1-5 Years

Over 5 years

How old are you?

Between 20 and 30

Between 30 and 37

Over 37

Have you been diagnosed with one of the following?

Endometriosis

PCOS

High FSH or Low AMH.

Unexplained Infertility

Fallopian Tube Scarring or Blockage

No/ No Diagnosis

Have you experienced pregnancy loss/miscarriage?

Yes, just one.

I have experienced multiple miscarriages

Never had a miscarriage.

I have had more than one abortion

How many miscarriages have you experienced?

1-5

5-10

10+

What was your longest pregnancy?

<6 weeks

<12 weeks

12 weeks +

Are you aware of having fibroids?

Yes

Yes, but they’ve been removed

Have you been diagnosed with Endometriosis?

Yes

How would you best describe your period?

Irregular and Infrequent

Irregular and painful

Regular and painful

Very light bleeding

Heavy Bleeding

Clotty

Do you get dizzy?

Yes

Do you get floaters in your eyes?

Yes

Is your belly colder below your belly button than above?

Yes

Do you experience loose stools or poor digestion?

On occasion

Frequently

Have you been diagnosed with “Incompetent Cervix?”

Yes

Do you have cramping with your period?

I don't have cramping with my period.

I have slight cramping with my period.

I have moderate cramping with my period. Occasionally I have to take something.

I have severe, sometimes debilitating cramping with my period.

Do you have a monthly period?

Yes, I bleed monthly and am very regular.

I have a period but it's not regular, meaning it may be more than a week late each month.

I don't have periods and haven't had one in over 3 months.

If you test for ovulation, do you ovulate regularly?

I don't test for ovulation.

I test for ovulation, and ovulate around mid-cycle each month.

I test for ovulation, but don't ovulate.

I test for ovulation, and tend to ovulate late, past day 17.

I test for ovulation, and tend to ovulate early, before day 12.

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