Women's Infertility Data Collection by Dr Mtonga N. Isaac

WOMEN'S INFERTILITY DATA COLLECTION

PLEASE ANSWER ALL THE QUESTIONS BELOW AND SUBMIT

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First Name Surname Age Township Town/City Phone Number Country

Women's Infertility Data Collection

Do you feel pain during menstruations? Yes No

Do you experience painful intercourse? Yes No

Have you ever been pregnant? Yes No

Have you ever had a miscarriage? Yes No

Have you had multiple miscarriages? Yes No

Have you had any previous surgery? Yes No

Have you ever had any sexually transmitted infections? Yes No

Have you ever been diagnosed with pelvic inflammatory disease PID? Yes No

Do you experience severe menstrual cramps or heavy bleeding? Yes No

Have you ever been diagnosed with uterine fibroids? Yes No

Have you ever been diagnosed with ovarian cysts? Yes No

Have you noticed changes in cervical mucus or vaginal discharge? Yes No

Have you noticed changes in your breast tissue or nipple discharge? Yes No

Have you ever had an ectopic pregnancy? Yes No

Do you experience sperm leakage after having sex? Yes No

Do you feel vaginal itchiness or dryness? Yes No

Do you sometimes experience high blood pressure or dizziness? Yes No

Do you have a growth inside your vagina? Yes No

Does your vaginal discharge experience bad odor and yellow in color? Yes No

Have you experienced any trauma or stress that may affect your fertility? Yes No

Do you have a family history of infertility or reproductive issues? Yes No

Have you experienced any symptoms of endometriosis? Yes No

Have you experienced irregular periods or infrequent menstruation? Yes No

Do you have symptoms of polycystic ovary syndrome (PCOS), such as acne or excess hair growth? Yes No

Have you noticed any changes in your libido? Yes No

Do you experience hot flashes or night sweats? Yes No

Have you been diagnosed with thyroid issues? Yes No

Do you experience mood swings or irritability? Yes No

Have you noticed any changes in your hair or skin? Yes No

Do you track your ovulation cycle? Yes No

Do you smoke or use tobacco products? Yes No

Do you consume alcohol or recreational substances? Yes No

Do you engage in regular exercise or physical activity? Yes No

Do you have a healthy diet and nutrition plan? Yes No

Have you experienced any significant weight changes? Yes No

Do you experience chronic stress or anxiety? Yes No

Have you been exposed to environmental toxins or pollutants that may affect fertility? Yes No

Do you work with or around chemicals that may affect fertility? Yes No

Have you been exposed to radiation or other hazardous materials? Yes No

Do you take any medications or supplements that may affect fertility? Yes No

Have you experienced any reproductive health issues due to your occupation? Yes No

Do you have a family history of reproductive health issues? Yes No

Have you been diagnosed with polycystic ovary syndrome (PCOS)? Yes No

Do you experience irregular ovulation or anovulation? Yes No

Have you been diagnosed with endometriosis? Yes No

Do you experience pelvic pain or cramping? Yes No

Have you been diagnosed with uterine abnormalities? Yes No

Do you experience heavy or prolonged menstrual bleeding? Yes No

Have you been diagnosed with fallopian tube blockage? Yes No

Do you experience painful intercourse? Yes No

Have you experienced any trauma or abuse that may affect your reproductive health? Yes No

Do you have a history of pelvic inflammatory disease (PID)? Yes No

Have you been diagnosed with ovarian reserve issues? Yes No

Do you experience hormonal imbalances or thyroid issues? Yes No

Have you been diagnosed with adenomyosis? Yes No

Do you experience bloating or digestive issues? Yes No

Have you been diagnosed with autoimmune disorders? Yes No

Do you experience chronic fatigue or exhaustion? Yes No

Have you been diagnosed with reproductive health issues due to genetic factors? Yes No

Have you considered fertility preservation options? Yes No

Do you have a history of multiple miscarriages? Yes No

Have you been diagnosed with luteal phase defect? Yes No

Do you experience symptoms of hormonal imbalance? Yes No

Have you been diagnosed with Asherman's syndrome? Yes No

Do you experience vaginal dryness or discomfort? Yes No

Have you been diagnosed with cervical stenosis? Yes No

Do you experience difficulty conceiving? Yes No

Have you experienced any reproductive health issues due to infections? Yes No

Have you been diagnosed with thyroid disorders that may affect fertility? Yes No

Do you have a history of diabetes or insulin resistance that may affect fertility? Yes No

Have you been diagnosed with pituitary gland disorders that may affect fertility? Yes No

Do you experience symptoms of adrenal gland disorders that may affect fertility? Yes No

Have you been diagnosed with autoimmune disorders that may affect fertility? Yes No

Do you experience symptoms of chronic inflammation that may affect fertility? Yes No

Have you been diagnosed with cancer or other serious medical conditions that may affect fertility? Yes No

Do you take any medications that may affect fertility? Yes No

Have you experienced any reproductive health issues due to surgeries or medical procedures? Yes No

Do you experience symptoms of polycystic ovary syndrome (PCOS) that affect fertility? Yes No

Have you been diagnosed with endometriosis that affects fertility? Yes No

Do you experience symptoms of uterine fibroids that affect fertility? Yes No

Have you been diagnosed with ovarian cysts that affect fertility? Yes No

Do you experience symptoms of pelvic inflammatory disease (PID) that affect fertility? Yes No

Have you been diagnosed with a blocked fallopian tube that affects fertility? Yes No

Do you experience symptoms of hormonal imbalance that affect fertility? Yes No

Have you been diagnosed with a condition that affects your reproductive health? Yes No

Do you experience stress or anxiety that affects your reproductive health? Yes No

Have you experienced any traumatic events that affect your reproductive health? Yes No

Do you have a history of substance abuse that affects your reproductive health? Yes No

Have you been exposed to toxins or pollutants that affect your reproductive health? Yes No

Do you experience sleep disturbances that affect your reproductive health? Yes No

Have you noticed any changes in your libido that affect your reproductive health? Yes No

Do you experience symptoms of depression that affect your reproductive health? Yes No

Have you been diagnosed with a reproductive health issue that affects your mental health? Yes No

Do you experience symptoms of anxiety that affect your reproductive health? Yes No

Have you noticed any changes in your menstrual cycle that affect your reproductive health? Yes No

Do you experience symptoms of premenstrual syndrome (PMS) that affect your reproductive health? Yes No

Have you been diagnosed with a hormonal imbalance that affects your reproductive health? Yes No

Do you experience symptoms of menopause that affect your reproductive health? Yes No

Have you noticed any changes in your body that affect your reproductive health? Yes No

Do you have any concerns about your reproductive health? Yes No

Please Write What is left out about your health situation below (Optional, 5000 characters)

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