Female Fertility Questionnaire

1. Do you suffer from any known allergies? YesNo
2. Have you been diagnosed with endometriosis? YesNo
3. Do you have polycystic ovarian syndrome? YesNo
4. Do you have regular periods? YesNo
5. Have you taken the contraceptive pill for more than 5 years? YesNo
6. Do you suffer with joint or muscular pains? YesNo
7. Have you suffered with eczema or other skin problems during or since childhood? YesNo
8. Do you suffer with recurrent hayfever or throat infections? YesNo
9. Do you experience regular symptoms of Irritable Bowel Syndrome? YesNo
10. Do you get frequent headaches or migraines? YesNo
11. Do you often get abdominal bloating? YesNo
12. Have you had more than 6 courses of antibiotics for infections in your life? YesNo
13. Do you suffer from persistent low energy? YesNo

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