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Birth Control
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Herpes Simplex Treatment
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Fertility
ASSESSMENT QUIZ
Answer the following questions to find out your fertility status
What’s your current age?
<21
21-30
31-40
41-50
Above 50
Are you currently married?
Yes
No
How long have you been attempting to initiate a pregnancy?
<1 year
1-2 years
2-3 years
3-4 years
More than 4 years
Do you regularly have sex with your partner?
Yes
No
Have you ever conceived a child prior to this?
Yes
No
Any difficulties in conceiving prior to this?
Yes
No
Are your periods regular?
Yes
No
Have you ever been diagnosed with any of these conditions?
Hormonal imbalance
PCOS
Endometriosis
Uterine polyps and/or fibroids
Pelvic Inflammatory Disease
Any STDs (Gonorrhea, Herpes, Chlamydia, Syphillis, Genital warts, etc.)
UTI and/or kidney disorders
None of the above
Have your partner ever been diagnosed with any of these conditions:
Cystic fibrosis
Varicocele
Previous injury to the scrotum or testicles
Premature ejaculation or other erection problems
Low sperm count or low testosterone
Testicular cancer
Any STDs (Gonorrhea, Herpes, Chlamydia, Syphillis, Genital warts, etc.)
I don’t know/None of the above
Have you or your partner ever been diagnosed with infertility?
Yes
No
Do you have diabetes?
Yes
No
Do you have anemia?
Yes
No
Have you ever been diagnosed with eating disorders?
Yes
No
Do you experience weight management problems, i.e. obesity or underweight?
Yes
No
Do you smoke?
Yes
No
Do you often consume alcohol?
Yes
No
How many glasses of alcohol do you typically consume in a week?
<1 glass/week
1-3 glasses/week
4-6 glasses/week
6-8 glasses/week
More than 8 glasses/week
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