Help! I need Fertility Support
Please enter your responses below for an opportunity to work with Dr. Aumatma, virtually.
First and Last Name
Your date of birth
What are your latest Lab test results for AMH, FSH, LH, and estradiol? (If the tests were not done in the US, please include units of measurement)
Average stress level?
No stress at all
Average energy level?
No energy at all
Energized all day
Do you have any of the following symptoms? #1
Do you have any of the following symptoms? #2
Heavy, irregular menses
Breast swelling and tenderness
Craving for sweets
Low thyroid symptoms
Do you have any of the following symptoms? #3
Do you have any of the following symptoms? #4
Sleep/ Drowsy feeling in the middle of the day
Do you have any of the following symptoms? #5
Diminished feeling of well being
Do you have any of the following symptoms? #6
Male pattern hair growth
Deepening of voice
loss of scalp hair
Do you have any of the following symptoms? #7
Cravings for sweets
Symptoms of hypothyroidism
Symptoms of low progesterone
Do you have any of the following symptoms? #8
Fatigue (especially evening)
Low body temperature
Intolerance to cold
General aches and pains
Scalp hair loss
Swollen, puffy eyes
Low pulse rate/blood pressure
Do you have any of the following symptoms? #9
Rapid heart rate
Do you currently experience any of the following? #10
Lack of energy to do the things you love
Waking up unrested
Gut-Brain: Do you currently experience any of the following?
Cravings for salt
Cravings for junk food
Cravings for sugar
Difficulty concentrating or forming words/sentences
Food allergies or sensitivities known or suspect
Post nasal drip
OB/GYN: Have you ever experienced or been diagnosed with any of the following?
PCOS (Polycystic Ovarian Syndrome)
Pelvic Inflammatory Disease
Chronic Pelvic Pain
How often do you and your partner have intercourse? Is it planned or spontaneous?
Do you use any lubricants/ gels before or during intercourse?
Have you used contraception in the past? If so, when and for how long?
Have you ever had a miscarriage? If so, when?
How long is your cycle on average? (# of days between day 1- start of next period)
How many days does your period last?
In what ways are you tracking your cycles? (BBTs, OPKs, beginning and end dates, etc) Please be specific.
Basal Body Temp
Beginning and end dates
What has your Fertility Journey been thus far? Please describe in detail.
What have you already tried and what kind of support are you looking for?
How much would you invest in getting the right type of support to optimize your fertility to get pregnant naturally or have a successful IVF cycle the next time you can?
Money is no object, I just want to get pregnant!
What time zone and country are you located in?
Do you have any questions or comments?
A copy of your responses will be emailed to the address you provided.
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