Fertility Baseline Assessment QuestionnaireSection IFull name Full nameGender GenderMaleFemalePhone number Phone numberEmail address Email addressHave you been diagnosed with any reproductive health conditions? Have you been diagnosed with any reproductive health conditions?e.g., PCOS, endometriosisHave you experienced any miscarriages or pregnancy complications? Have you experienced any miscarriages or pregnancy complications?If yes, please provide details.Have you undergone any fertility treatments? Have you undergone any fertility treatments?If yes, please specify.Do you have a history of sexually transmitted infections (STIs)? Do you have a history of sexually transmitted infections (STIs)?Are you currently trying to conceive? Are you currently trying to conceive?If yes, for how long?Section IIMenstrual Health (for women)At what age did you have your first menstrual period? At what age did you have your first menstrual period?Are your menstrual cycles regular? Are your menstrual cycles regular?If not, please provide details.How long is your average cycle? How long is your average cycle?e.g. 28 daysDo you experience any symptoms during your cycle? Do you experience any symptoms during your cycle?e.g. heavy bleeding, crampsSection IIILifestyle FactorsDo you smoke or consume alcohol? Do you smoke or consume alcohol?If yes, how frequently?Are you exposed to environmental toxins or hazardous chemicals? Are you exposed to environmental toxins or hazardous chemicals?If yes, please provide details.How often do you engage in physical activity? How often do you engage in physical activity?What type of activities?Describe your current stress levels and how you manage stress. Describe your current stress levels and how you manage stress.Section IVDietary HabitsDo you consume a balanced diet that includes essential nutrients for reproductive health? Do you consume a balanced diet that includes essential nutrients for reproductive health?e.g. folic acid, ironHow often do you consume processed or fast foods? How often do you consume processed or fast foods?Do you take any supplements? Do you take any supplements?If yes, please list themSection VPartner Information (if applicable)Has your partner undergone any fertility assessments? Has your partner undergone any fertility assessments?Does your partner have any known reproductive health issues? Does your partner have any known reproductive health issues?Are there lifestyle factors that may impact your partner’s fertility? Are there lifestyle factors that may impact your partner’s fertility?e.g. smoking, alcohol useIs there anything else you would like us to know about your health or concerns? Is there anything else you would like us to know about your health or concerns?
Full name
Gender
Phone number
Email address
Have you been diagnosed with any reproductive health conditions?
e.g., PCOS, endometriosis
Have you experienced any miscarriages or pregnancy complications?
If yes, please provide details.
Have you undergone any fertility treatments?
If yes, please specify.
Do you have a history of sexually transmitted infections (STIs)?
Are you currently trying to conceive?
If yes, for how long?
At what age did you have your first menstrual period?
Are your menstrual cycles regular?
If not, please provide details.
How long is your average cycle?
e.g. 28 days
Do you experience any symptoms during your cycle?
e.g. heavy bleeding, cramps
Do you smoke or consume alcohol?
If yes, how frequently?
Are you exposed to environmental toxins or hazardous chemicals?
How often do you engage in physical activity?
What type of activities?
Describe your current stress levels and how you manage stress.
Do you consume a balanced diet that includes essential nutrients for reproductive health?
e.g. folic acid, iron
How often do you consume processed or fast foods?
Do you take any supplements?
If yes, please list them
Has your partner undergone any fertility assessments?
Does your partner have any known reproductive health issues?
Are there lifestyle factors that may impact your partner’s fertility?
e.g. smoking, alcohol use
Is there anything else you would like us to know about your health or concerns?
