How do we contact you?

First Name

Phone *

Email *

Let's see where you are...

Are you currently trying to get pregnant? *

Yes, actively trying

Not yet, but soon

No, just exploring options

How long have you been trying to conceive? *

Less than 3 months

3-6 months

6-12 months

Over a year

Let's talk a little about your fertility journey so far...

Which of the following have you tried or are considering? *

IVF

IUI

Acupunture

Prayer

Supplements

Natural Tracking

None yet

(Please select all that apply)

Have you ever taken a saliva test for hormones? *

Yes

No

I don't know

Let's take a look at your hormonal health...

What is your age group? *

20-26

27-33

34-40

40+

When did you last take birth control pills? *

Within the last month

A few months ago

A few years ago

Never

How would you describe your period? *

Irregular

Light

Heavy

Non-existent

Pretty normal

How long is your cycle? *

Less than 25 days

28-35 days (regular)

More than 35 days

No period at all

Not sure

Let's look at lifestyle...

Which of these is a part of your current lifestyle? *

Stress

Lack of sleep

Intense exercise

Caffeine (coffee, tea, soda, energy drinks, etc)

Difficulty making decisions

Irritability

None of these

(Please select all that apply)

What's in your regular diet *

Processed foods

Carbs

Dairy

Diet soda

Chocolate

Coffee

Sweets (sugar)

(Please select all that apply)

Let's see about any symptoms you have ever experienced...

Have you experienced any of the following? *

Night sweats

Hot flashes

PMS

Irregular or missed periods

PCOS

Thyroid issues

Sleeplessness

Brain fog

Endometriosis

Miscarriage

(Please select all that apply)

How motivated are you...

On a scale of 1-5, how ready are you to explore a natural solution? *

1

2

3

4

5

(1 = Just curious, 5 = Let's do this)

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