Get a Personalized plan for your Fertility Problems.
Fill out this Form
Q1.
Please enter your phone number
*
+91
Q2.
How regular are your periods?
*
Choose one option
A
Mostly regular every 28-30 days
B
Irregular every few months
C
Not sure I don't track them
Q3.
Do you have especially heavy or painful menstrual periods?
*
Choose one option
A
Yes I have
B
No I don't have
Q4.
How long have you been trying to get pregnant without any medical assistance?
*
Choose one option
A
6 Months
B
1 year
C
More than 2 years
Q5.
Have you ever been pregnant before?
*
Choose one option
A
Yes
B
No
Q6.
Have you ever had a miscarriage?
*
Choose one option
A
Yes I had
B
No I never had
C
Not Sure about it
Q7.
Are you in good overall health?
*
Choose one option
A
Yes overall health is good
B
No overall health is not good
C
Not Sure about overall health
Q8.
Have you ever been diagnosed with the following? Check all that apply.
*
Choose as many as you like
A
Endometriosis
B
Sexually Transmitted Disease
C
Pelvic Inflammatory Disease
D
Uterine Fibroids
E
PCOS
F
None of the above
Q9.
Is there a history of any genetic disorders or diseases within your family?
*
Choose one option
A
Yes on my mother's side of the family
B
Yes on my father's side of the family
C
Yes on both sides of the family
D
None
E
Not Sure of any genetic disorders
Q10.
Has your partner ever been evaluated for his sperm count?
*
Choose one option
A
Yes evaluated for sperm count
B
No not evaluated for sperm count
Q11.
Has your male partner had problems with ejaculation, general infections, or erections?
*
Choose one option
A
Yes partner had problems
B
No partner had no problems
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