About getting Pregnant What is your age group? Under 34 years Over 34 years

How long have been trying to get pregnant? 0 - 6 months 6 - 12 months more than 12 months

Reproductive History Do your usually suffer period pains? Yes No

Have you had pelvic surgery? Yes No

Do you still experience a peroid (when not using contraceptive)? Yes No

Is your mentrual cycle is predictable(when not using contraceptive)? Yes No

Is your mentrual cycle last less than 21 days or more than 35 days(when not using contraceptive)? Yes No

Do suffer endometriosis? Yes No

Do you have pelvic inflamatory disease(PID)? Yes No

Your Life Style Do you have unprotected sex with multiple partners? Yes No

Do you smoke (cigeratte) or drink(Alcohol and carreine) excessively? Yes No

Are you currently stress? Yes No

Do you have sexually transmitted infection? Yes No

Have you taken class A drug(e.g. marijuana, heroin or cocaine) in the past? Yes No

Do you take anabolic steroid? Yes No

Are you obese or under weight? Yes No