1. Have you seen your Dr. for a physical
examination (including Pap smear) in the past 12-months)?
2. Are you using any form of contraceptive
that could prevent pregnancy (condoms, spermacides, etc)
3. Which of the following supplements do
a. Dr.prescribed prenatal vitamin
b. Store-brand prenatal vitamin
c. Daily multivitamin (ex: Centrum)
d. No vitamin supplements
4. Which of the following best describes
the frequency of intercourse during your cycle:
a. Every 48 hours when observing fertile cervical mucous
b. Every 24 hours when observing fertile cervical mucous
c. Every day.
d. I am not observing cervical mucous to time intercourse
5. Which of the following are you doing to
determine when you are ovulating?
a. Observing cervical mucous
b. Checking cervical position
c. Charting your basal body temperature
d. Using ovulation predictor kits
e. All of the above
f. None of the above
6. Check all that apply to your husband:
7. Check all that apply to you:
8. How many hours sleep do you get per night?
I have insomnia
9. My Luteal phase is 14 days?
10. For lubrication during intercourse, do you use:
11. When having intercourse, which position
do you use:
a. Missionary (man on top)
b. Rear-entry ("doggie-style")
c. Woman on top
45- 60 points "Fertile Myrtle" - Your lifestyle will maximize
your chances for conception and healthy pregnancy. Good for you!!
35- 44 points "Taking Time Tess" - There are areas in your lifestyle that could
be changed to improve your odds for conception.
0- 34 points "Silly Sally" - Yikes! If you want to get pregnant, stop and listen!