Assessment Name* First Last Email* Phone*Age*20-3031-3536-4040+ Have you been diagnosed with any of the following? Irregular Menstrual Cycle Severe Menstrual Cramps Heavy menstrual bleeding PCOS Ovarian cysts Endometriosis Fibroids Perimenopausal symptoms (e.g. hot flashes, irregular periods) Menopause Vaginal issues (e.g. yeast infections, BV, vaginal dryness) PMS or PMDD Low libido Adrenal and thyroid issues Acne Prepping or healing from a surgery (e.g. ruptured ovarian cyst, fibroid removal, hysterectomy) Breast health (e.g. fibrocystic breasts) Unsure of which applies but you feel you’ve got a hormonal imbalance Diagnosed with Unexplained Infertility Unexplained weight gain over the last 12 months Low Thyroid Hashimoto’s Disease Grave Disease Digestive Issues Tendency towards constipation Poor quality of sleep Would you consider yourself healthy?YesNoHave you had any recent blood work done (within the last 6 months) for the treatment of infertility?YesNoAre you currently undergoing treatment for fertility?YesNoHave you received treatment for IVF?YesNoHave you received treatment for artificial insemination?YesNoHow long have you been trying to conceive?Just starting1 year2 yearsOver 2 yearsHow would you rate your level of overall stress during the week?LowMediumHighAre you taking any prescription medications for your thyroid?YesNoHow would you rate your diet?ExcellentGoodNot so goodDo you use tobacco?YesNoDo consume cannabis?NeverOnce a week2 - 3 times per weekOver 4 times per weekDo you consume alcohol?Never1 - 2 times/monthOnce on the weekends2 - 3 times/weekMore than 3x / weekAre you being treated for any autoimmune illnesses?YesNoAre you taking any prescription medication?YesNoHas the quality of your husband’s sperm been checked?YesNoPhoneThis field is for validation purposes and should be left unchanged.
