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Female Assessment
1.
Please indicate your age group.
Select one
<20
20-25
26-30
31-35
36-40
>40
2.
How long have you been actively trying to achieve a pregnancy?
select one
<3 months
3-6 months
7-12 months
13-24 months
>24 months
3.
How many times, on average, do you and your partner have intercourse in a month?
select one
<1
1-4
5-10
11-20
21-30
>30
4.
Do you experience pain after or during intercourse?
Yes
No
5.
Do you have a blockage in the fallopian (uterine) tubes?
Yes
No
Unknown
6.
Have you had previous infections in the fallopian tubes?
Yes
No
Unknown
7.
Do you have any abnormalities of the uterus?
Yes
No
Unknown
8.
Do you suffer from endometriosis?
Yes
No
Unknown
9.
Do you have irregular periods?
Yes
No
Unknown
10.
Does your partner have a low sperm count?
Yes
No
Unknown
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