Let's Conceive

0%

Name

Age

Gender

Height

Weight

City

Contact phone

13%

Which of the below problems you are facing right now?*

Weight Management

Thyroid

PCOD / PCOS

Diabetes / Insulin resistance / Hba1c

Hormonal Imbalance

Cholesterol / Triglycerides

Poor Egg Quality / Sperm Quality

Sleep Disorder / Insomnia

Nutritional Deficiency

Inflammation / Infection

Gut Health

Liver Health

Total Detoxification

Stress Management

Ovarian Cyst

Endometriosis

Irregular Periods

Depression, Anxiety, Mood Swings

Peri-menopause

Auto-Immune Conditions

Eczema / Psoriasis / Rosacea

Unexplained Infertility

I don't know about my problems exactly, but would like to Improve my Overall Health.

15%

How long have you been trying to conceive?

Less than 6 Months

6 month to 12 months

1-2 year

More than 2 years

17%

Which of the following best describes your current situation?

Trying to conceive (TTC), had a miscarriage / abortion before

TTC never conceived before

Planning for second child

19%

What type of treatment have you taken? Or are you planning to take?

21%

Are you currently taking any Medications / Supplements? If yes, please specify name and doses (e.g., Thyronorm - 50mcg)

24%

Have you experienced any sudden or unexplained changes in your weight in the last 6 months?

My weight has remained stable

I have gained weight (up to 5 kg)

I have gained significant weight (more than 5 kg)

I have lost weight (up to 5 kg)

I have lost significant weight (more than 5 kg)

I am not sure about any changes

26%

28 How would you describe your overall energy levels throughout the day?

I have consistent high energy throughout the day

I experience some dips in energy but manage well

I often feel fatigued but can push through

I frequently feel exhausted and struggle to stay energized

My energy levels fluctuate significantly day by day

28%

Do you experience fatigue or tiredness even after a full night's sleep?

I wake up feeling refreshed and rested

I sometimes feel tired, but not every day

I often feel tired after a full night’s sleep

I always feel fatigued, no matter how much I sleep

30%

Do you experience recurring symptoms like headaches, joint pain, or muscle aches?

No, I rarely experience these symptoms

I experience mild symptoms occasionally

I frequently experience moderate symptoms

I experience severe symptoms almost daily

32%

Are your menstrual cycles regular (every 28-32 days)?

Yes, my cycles are always regular

My cycles are mostly regular but vary slightly (by a few days)

My cycles are often irregular, varying by more than a week

My cycles are very irregular, or I have missed periods

33%

How long is your typical menstrual cycle?

24-26 days

27-29 days

30-32 days

More than 32 days

Less than 24 days

35%

How many days does your period last?

2-3 days

4-5 days

6-7 days

More than 7 days

37%

Do you experience painful periods (cramps, heavy bleeding, clotting, etc.)?

No, my periods are pain-free

I experience mild discomfort that does not require medication

I experience moderate pain, which sometimes requires over-the-counter medication

I experience severe pain, which impacts my daily activities and requires medication

39%

Do you experience spotting between periods?

No, I do not experience spotting

Rarely, I spot once or twice a year

Occasionally, I spot every few months

Frequently, I spot between most cycles

40%

Do you experience mood swings, anxiety, or depression around your menstrual cycle?

No, my mood remains stable

I occasionally experience mild mood swings

I frequently experience moderate mood swings or anxiety

I experience severe mood swings, anxiety, or depression that impacts my daily life

43%

Do you experience breast tenderness or swelling before or during your period?

No, I do not experience breast tenderness

I experience mild tenderness occasionally

I experience moderate tenderness frequently

I experience severe tenderness or swelling regularly

45%

Do you experience hot flashes, night sweats, or difficulty sleeping?

No, I do not experience any of these symptoms

I occasionally experience one or two symptoms

I frequently experience moderate discomfort

I experience severe symptoms that disturb my sleep regularly

47%

How would you describe your stress levels on a typical day?

I experience little to no stress

I experience moderate stress but manage it well

I frequently feel stressed and it affects my mood

I feel very stressed, and it impacts my daily activities

49%

How do you manage stress?

I engage in relaxation techniques like yoga, meditation, or mindfulness

I use physical activity or exercise to manage stress

I talk to friends, family, or a therapist for support

I do not actively manage my stress

51%

Do you sleep well at night?

Yes, I sleep 7-9 hours and feel rested

I sleep 5-7 hours but sometimes feel tired

I have difficulty falling or staying asleep frequently

I have insomnia or regularly wake up during the night

54%

Do you smoke?

No, I don’t smoke

I smoke occasionally, socially

I smoke regularly, several times a week

I smoke heavily on a daily basis

56%

Do you consume alcohol?

No, I don’t drink alcohol

I drink occasionally, socially

I drink regularly, several times a week

I drink heavily on a daily basis

58%

How often do you engage in physical activity?

Daily or almost daily, I exercise regularly

A few times a week

Once a week or less

I do not exercise regularly

60%

How would you describe your diet?

I eat a well-balanced diet with whole foods

I eat mostly healthy but indulge occasionally

I eat processed or fast foods often

My diet is poor, and I struggle to make healthy choices

62%

Do you experience frequent bloating, gas, or constipation?

No, my digestion is regular and without discomfort

I occasionally experience mild digestive discomfort

I frequently experience moderate digestive issues

I regularly experience severe bloating, gas, or constipation

65%

Do you often crave sugar, salt, or carbohydrates?

No, I rarely have cravings

I occasionally crave specific foods, but it’s manageable

I frequently have moderate cravings

I have intense cravings daily, especially for sugar or carbs

67%

How much water do you drink daily?

More than 2.5 liters daily

1.5-2 liters daily

1-1.5 liters daily

Less than 1 liter daily

69%

Have you ever experienced a miscarriage?

No, I’ve never had a miscarriage

Yes, I’ve had one miscarriage

Yes, I’ve had two miscarriages

Yes, I’ve had three or more miscarriages

71%

Have you undergone fertility treatments (e.g., IVF, IUI)?

No, I have not undergone any fertility treatments

Yes, I’ve had one round of treatment

Yes, I’ve had multiple rounds of treatment

Yes, I am currently undergoing treatment

73%

Are you frequently exposed to environmental toxins or chemicals?

No, I’m not exposed to toxins or chemicals

Yes, I’m occasionally exposed to environmental chemicals (e.g., at work)

Yes, I am regularly exposed to chemicals at work or in my home environment

I’m not sure about my level of exposure

76%

Do you use personal care products that contain chemicals (e.g., parabens, sulfates)?

No, I use mostly natural products

Yes, but I use a mix of natural and chemical products

Yes, I regularly use products containing chemicals

I’m not sure about the ingredients in my personal care products

78%

Have you taken any blood test in the last 12 months?

80%

What is your daily routine? (How many meals a day do you have?)

82%

Which of the following best describes your dietary preference?

Vegetarian (no meat, fish, or poultry)

Eggetarian (vegetarian but includes eggs)

Non-vegetarian (includes meat, fish, or poultry)

83%

Do you have any allergies to the following food items?

Peanuts

Shellfish (e.g., shrimp, crab)

Dairy products (e.g., milk, cheese)

Eggs

I do not have any food allergies

84%

What food items do you have in Breakfast regularly? At what time?

90%

What food items do you have in Lunch regularly? At what time?

93%

What food items do you have in Dinner regularly? At what time?

97%

Are you a tea or coffee addict? How many cups in a day? Can you avoid it?

100%

Mention periods date of last 6 months

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