Family history (check any that apply)

Diabetes Heart disease / high blood pressure Cancer Thyroid conditions Mental health conditions

Occupation / nature of work

Physical activity level

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Exercise frequency (optional)

Lifestyle (all optional)

Allergies & reactions (all optional)

Past diagnoses, surgeries, or ongoing conditions (optional, one per line)

Women's health (all optional -- skip anything you'd rather not answer)

Age at first period

Cycle

Select... Regular Irregular

Approximate cycle length & period duration

Typical flow

Select... Light Moderate Heavy

Notable period symptoms (check any that apply)

Pain Heavy bleeding Mood changes Irregular bleeding

Current contraception method, if any

Pregnancy history (number of pregnancies, complications)

Currently pregnant or postpartum?

Select... No Pregnant Postpartum

Trying to conceive / planning to soon?

Select... Yes No

Menopause status

Select... Not yet Perimenopausal Post-menopausal