Fertility Yoga Assessment Form

Personal Information

Name

Age

Contact Number

Address

Occupation

Emergency Contact

Health Background

Have you been diagnosed with any reproductive health conditions such as PCOS, endometriosis, thyroid disorders, or others? If yes, please specify.

Do you have a history of irregular menstrual cycles or hormonal imbalances?

Are you currently taking any medications or supplements?

Have you undergone any recent surgeries or experienced any injuries?

Reproductive History

Are you currently trying to conceive? If yes, how long have you been trying?

Have you undergone any fertility treatments, such as IUI or IVF?

Do you commonly experience symptoms like menstrual cramps, bloating, or mood changes?

Lifestyle and Wellness

How would you rate your stress levels on a scale of 1 to 10?

What is your current diet (e.g., vegetarian, non-vegetarian, vegan, etc.)?

How would you describe your sleep patterns (e.g., hours of sleep, quality, consistency)?

What does your exercise routine look like (e.g., frequency, type of activities)?

Goals for Fertility Yoga

What are your primary goals for practicing fertility yoga? (e.g., reducing stress, improving hormonal balance, enhancing fertility, etc.)