Let's Conceive

0%

Name

Age

Weight

In

Height

City

Country Code

Phone no.

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)

23%

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

25%

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%

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

34%

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

36%

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

38%

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

40%

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

42%

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

44%

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

46%

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

48%

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

50%

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

52%

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

54%

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

56%

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

58%

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

60%

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

62%

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

64%

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

66%

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)

68%

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

70%

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

72%

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

74%

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

76%

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

78%

1. Do you experience difficulty in getting or maintaining an erection?

No, never

Occasionally

Often

Almost always

80%

2. Have you ever had a semen analysis?

Yes

No

Not sure

82%

3. Are you aware of any issues with your sperm health?

Normal sperm parameters

Low sperm count

Poor motility

Abnormal morphology

Not sure / Never tested

84%

4. How often do you have sexual intercourse?

Less than once a week

1–2 times a week

3–4 times a week

5 or more times a week

88%

5. Do you currently experience any of the following? (Select all that apply)

Low sex drive (reduced desire)

Pain or discomfort in the testicles

Premature ejaculation

Delayed ejaculation

None of the above

92%

6. Do you have any medical history related to reproductive health? (Select all that apply)

Varicocele (enlarged veins in the scrotum)

Undescended testicles

Mumps after puberty

Testicular injury or surgery

Hormonal disorders (e.g., thyroid, testosterone imbalance)

Diabetes or other chronic illnesses

None of the above

96%

7. Are you currently using, or have you previously used, any of the following? (Select all that apply)

Anabolic steroids or testosterone supplements

Alcohol (more than 3–4 drinks/week)

Tobacco (smoking or chewing)

Recreational drugs (e.g., cannabis, cocaine)

Long-term medications (e.g., antidepressants, anti-hypertensives)

None of the above

100%

8. Are you regularly exposed to any of the following? (Select all that apply)

Prolonged sitting (e.g., desk job, frequent driving)

High heat exposure (e.g., saunas, hot baths, laptops on lap)

Radiation, heavy metals, or industrial chemicals

Tight-fitting underwear or pants

All of the above

None of the above

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