| Gender
choice |
|
| Your
date of birth |
|
| Your
blood type |
|
| Select
start month of your 12 month calendar |
|
| Age
at which your first period occured : |
years old |
| Are
you using the pill/coil |
|
|
Date of the start of your last period* : |
|
| Your
period cycle |
|
| days
between ovulation & last period day |
|
| Are
your periods regular or irregular |
|
| How
many children by your present partner |
Boys :
; Girls :
|
| How
many months did you take to achieve your last 2 conceptions |
and
|
| Do
you take medication to increase your fertility |
|
