Fertility Consultation Test
Your Main Concern
How long have you trying to conceive?
How frequently do your periods come? (Last 3 month period.)
How long do your periods last?
How would you describe the amount of your periods? *
What is the colour of your period? *
Do you have blood clots during your period? *
Do you have white discharge between periods? *
If yes, what is the nature?
Do you experience cramping with your periods? *
If yes, when during your cycles do you have pain (check all that apply)
How would you describe the cramps?
Do you have other symptoms with your periods? Or general? *
If any applies, when during your cycles do you have these symptoms (check all that apply)
Do you bleed or spot between periods? *
Have you ever had any of the following infections involving any part of the reproductive system?
Have you ever used contraception in the past? *
Have you been treated for infertility previously? *
Have you ever attempted in vitro fertilization (IVF)? *
Have you had a miscarriage before? *
Do you have the following conditions?
Did you have surgery on these?
Do you consume meat or follow a vegetarian/vegan diet?
Where did you hear about us?
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