Full Name Full NameClear selectionGender GenderChooseMaleFemaleClear selectionMarital Status Marital StatusClear selectionPhone Number Phone NumberClear selectionEmail Address Email AddressClear selectionDo you have any diagnosed medical conditions? Do you have any diagnosed medical conditions?(e.g., hypertension, diabetes, asthma)Clear selectionAre you currently taking any medications or supplements? Are you currently taking any medications or supplements? If yes, please list them.Clear selectionHave you had any surgeries or hospitalisations in the past five years? Have you had any surgeries or hospitalisations in the past five years?Please provide detailsClear selectionDo you have a family history of chronic illnesses? Do you have a family history of chronic illnesses?If yes, specify.Clear selectionDo you have any allergies? Do you have any allergies?(medications, foods, etc.)Clear selectionHave you experienced any significant changes in your health recently? Have you experienced any significant changes in your health recently?Clear selectionOn average, how many hours of sleep do you get each night? On average, how many hours of sleep do you get each night?Clear selectionHow often do you engage in physical activity? How often do you engage in physical activity?(e.g., daily, weekly, rarely)Clear selectionWhat types of physical activities do you enjoy or currently participate in? What types of physical activities do you enjoy or currently participate in?Clear selectionHow would you describe your stress levels? How would you describe your stress levels?(e.g., low, moderate, high)Clear selectionHave you experienced recent weight changes? Have you experienced recent weight changes?Clear selectionDo you follow a specific diet or nutrition plan? Do you follow a specific diet or nutrition plan?Clear selectionHow many meals do you eat per day? How many meals do you eat per day?Clear selectionDo you regularly consume fruits and vegetables? Do you regularly consume fruits and vegetables?How many servings per day?Clear selectionDo you often eat out or rely on packaged/processed foods? Do you often eat out or rely on packaged/processed foods?If yes, how frequently?Clear selectionDo you drink water regularly? Do you drink water regularly?If not, what beverages do you primarily consume?Clear selectionSection IIPlease answer the following questions that apply to youAge at first period Age at first periodClear selectionAre your periods regular? Are your periods regular? YesNoClear selectionLast menstrual period Last menstrual periodClear selectionAre you currently pregnant or trying to conceive? Are you currently pregnant or trying to conceive? YesNoClear selectionAre you experiencing any of the following menopausal symptoms? Are you experiencing any of the following menopausal symptoms?Check all that applyHot flashesNight sweatsMood changes (e.g. irritability, depression, anxiety)Vaginal drynessReduced libidoSleep disturbancesMemory or concentration issuesOther:Clear selectionAre you experiencing any of the following Are you experiencing any of the followingCheck all that applyLeaking urine when you laugh, cough, sneeze, or exerciseUrgent or frequent need to urinateDifficulty starting urination or emptying your bladder fullyPain or pressure in your pelvic regionPain during or after sexual intercourseA feeling of heaviness or bulging in the vagina or rectumConstipation or straining during bowel movementsInability to control wind or stoolPelvic pain that interferes with daily activitiesLower back pain without an obvious causePainful periods or cramps that worsen with activityDifficulty inserting tampons or menstrual cupsClear selectionHow long have you experienced these symptoms? How long have you experienced these symptoms?Less than 1 month1–3 months3–6 monthsMore than 6 monthsClear selectionHave these symptoms worsened over time? Have these symptoms worsened over time?YesNoNot sureClear selectionAre these symptoms affecting your daily life or quality of life? Are these symptoms affecting your daily life or quality of life?YesNoNot sureClear selectionHave you had any previous pelvic surgeries or injuries? Have you had any previous pelvic surgeries or injuries?Clear selectionHave you given birth vaginally or via C-section? Have you given birth vaginally or via C-section?if applicableClear selectionIs 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?Clear selectionRestart
Full Name
Gender
Marital Status
Phone Number
Email Address
Do you have any diagnosed medical conditions?
(e.g., hypertension, diabetes, asthma)
Are you currently taking any medications or supplements?
If yes, please list them.
Have you had any surgeries or hospitalisations in the past five years?
Please provide details
Do you have a family history of chronic illnesses?
If yes, specify.
Do you have any allergies?
(medications, foods, etc.)
Have you experienced any significant changes in your health recently?
On average, how many hours of sleep do you get each night?
How often do you engage in physical activity?
(e.g., daily, weekly, rarely)
What types of physical activities do you enjoy or currently participate in?
How would you describe your stress levels?
(e.g., low, moderate, high)
Have you experienced recent weight changes?
Do you follow a specific diet or nutrition plan?
How many meals do you eat per day?
Do you regularly consume fruits and vegetables?
How many servings per day?
Do you often eat out or rely on packaged/processed foods?
If yes, how frequently?
Do you drink water regularly?
If not, what beverages do you primarily consume?
Age at first period
Are your periods regular?
Last menstrual period
Are you currently pregnant or trying to conceive?
Are you experiencing any of the following menopausal symptoms?
Check all that apply
Are you experiencing any of the following
How long have you experienced these symptoms?
Have these symptoms worsened over time?
Are these symptoms affecting your daily life or quality of life?
Have you had any previous pelvic surgeries or injuries?
Have you given birth vaginally or via C-section?
if applicable
Is there anything else you would like us to know about your health or concerns?
