First name *
Email Address *
How long have you been Trying to Conceive? *
-- Please select --
Soon
1-3 Months
4-6 Months
6-12 Months
1-3 Years
More than 3 Years
Your Age *
Partner's Age *
How long are your cycles? *
-- Please select --
Less than 23 days
23-27 days
28-36 days
37-45 days
1-3 per year
can't remember
I have no idea
Start of last menstrual period? (LMP)
Country or US State
Are you able to predict ovulation?
-- Please select --
No
Yes
Sometimes
If yes, how do you predict Ovulation? Choose all that apply
How long is your luteal phase? *
-- Please select --
6-10 days
11-13 days
14 days
15-16 days
No idea
Describe your period (3 days, heavy at first, w/pain)
Have you ever been pregnant? If so, how many times?
-- Please select --
None
1
2
3
4
5
6
7
8+
Have you had any miscarriages? If so, at what week?
How much do you weigh (weight)
Describe your physical health
Any Surgeries (e.g., lap, C-section, D&C etc.)
What do you think is going on
What is your best quality?
How many hours of sleep do you get per night
Bowel Movements per day?
Are you a vegetarian? If so what kind
What are your favorite comfort foods?
How tall are you? (height)
Any Physical Challenges?
Are you living with pain? Please explain
What do you do for a living (Occupation/Profession)
Are you under any stress?, If so, what is creating stress in your life
Do you have a stressed body part (e.g., neck, headaches, back pain, etc.)
Family Medical History (e.g., PCOS, heart attack, early menopause, fibroids, miscarriage)
Medical Conditions
Medications
Do you have any pets?
What makes you laugh?
Hopes and/or fears
Anything not covered
Prove you're not a robot *
Tell me about yourself and send. 
