Cycle Assessment Name * First Name Last Name Phone * (###) ### #### Email * DOB * MM DD YYYY Time of Birth (if known) Hour Minute Second AM PM Place of Birth (city, state) * Do you currently get a menstrual period? Yes No Irregularly When was the first day of your last period? MM DD YYYY Do you notice any common patterns or symptoms with your cycle (cramps, breast tenderness, spotting, emotional changes)? How many pregnancies have you experienced? Live births Pregnancy releases None For each pregnancy or pregnancy release, please share how long it took for your cycle to return: Year | Type (birth or release) | Breastfeeding? | Cycle returned after ___ weeks/months | Notes Are you currently breastfeeding? Yes—exclusive Yes—partial/weaning No If yes, what is baby’s age? Are you currently using any form of birth control? Not at the moment Hormonal pill Condom or barrier method Withdrawal method IUD (hormonal or copper) Implant (e.g. Nexplanon) Natural or fertility awareness method Hormonal shot (e.g. Depo-Provera) Vaginal ring (e.g. NuvaRing) Patch Emergency contraception (Plan B or similar) Other Have you used hormonal birth control in the past? Yes No If yes, which kinds and for how long? When did you stop? (e.g., pill, IUD, implant, shot, ring) How has your body responded to it (physically, emotionally, or hormonally)? Do you have any diagnosed health conditions that affect your cycle or fertility? Not that I know of PCOS Endometriosis Thyroid Imbalance Autoimmune Other Have you had any surgeries, procedures, or injuries related to reproductive health? Yes No Do you experience any of the following? (Check all that apply) Painful periods Irregular or missing periods Heavy bleeding Spotting between periods Pain with sex Recurrent yeast or BV Difficulty conceiving PMS or PMDD Other How many hours of sleep do you typically get each night? Less than 5 5-6 7-8 More than 9 Do you often wake up feeling rested and refreshed? Yes Sometimes Rarely No How many meals do you eat in a typical day? 1 2 3 4 and snacks How often do you eat within an hour of waking up? Always Most days Some days Rarely Never Do you currently drink caffeine? If so, how much per day? None 1 small cup of coffee or tea 1–2 cups (or one large coffee) 3+ cups or caffeine throughout the day (coffee, tea, energy drinks, soda, etc.) How much water do you drink on average per day? Just a few sips here and there 1–2 regular water bottles 3–4 water bottles 5+ water bottles How often do you exercise or move your body in ways that feel good to you? Daily A few times a week Once a week or less Not often Do you spend time outside in natural light most days? Yes Sometimes No How would you describe your overall capacity or energy levels lately? I feel grounded and resourced most days I’m managing, but some days feel heavier than others I’m often running on empty I feel like I’m barely getting by Which areas of life feel like they’re taking up the most of your energy right now? Work or career Parenting or caregiving Relationships or family dynamics Finances Health or physical wellbeing Emotional processing or past experiences Not sure, it just feels like a lot Other Do you have any current tools or practices that help you feel calm or supported? Yes No, not really What are your current fertility intentions? Trying to conceive Avoiding pregnancy Transitioning off of hormonal birth control Learning and observing my cycle/body Other Are you currently tracking your cycle in any way? Yes No If you're tracking your period through an app, which app are you using? Follow up: In your app, what is being tracked/what insights are you seeing? prediction of the next bleed ovulation/fertile window prediction bbt cervical fluid mood/energy physical symptoms sexual activity OPKs Blood pressure Other Have you observed any of these types of cervical fluid throughout your cycle? (Check all that applies) Dry Sticky/Tacky/Rubbery Creamy/Milky Egg White/Slippery Watery Are you familiar with or currently observing any of the following? Basal Body Temperature (BBT) Cervical Fluid Cervical Height, Firmness, Openness Would you like to learn how to observe and chart: BBT Cervical Fluid Cervical Height Cervical Firmness Cervical Openness Do you feel when you ovulate? Yes, I can always tell — my body gives clear signs Sometimes — I think I feel something, but I’m not 100% sure No, I don’t notice anything I’ve never really paid attention before I’m not sure what I should be looking for I’ve had medical suppression (birth control, removal of ovaries, anovulatory cycles, etc.) If you do feel something, what are your signs? Ovulation pain (twinge or cramping, often on one side) Increased libido (feeling more turned on) Egg white cervical fluid (clear, stretchy) Slippery/Lubricative vaginal sensation Higher energy or mood shift Breast tenderness Slight spotting or pink discharge Other What day of your cycle do you typically suspect ovulation? What do you usually crave in each part of your cycle (or what are you craving now)? How comfortable are you with tracking/observing your cervical fluid? Your body produces cervical fluid throughout your cycle, and its texture and sensation can indicate where you are in your fertile window. This involves noticing discharge on your underwear, when you wipe, or by checking at the vaginal opening. It ranges from dry/sticky to creamy to clear/stretchy like egg whites (the most fertile type). Pretty comfortable or curious Neutral, not opposed to it Nervous or uncomfortable How comfortable are you with tracking your basal body temperature (BBT)? BBT is your body’s resting temperature, taken first thing in the morning before getting up or doing anything. It helps identify ovulation after it happens and can show overall cycle health when charted daily using a thermometer or wearable device like Tempdrop. Pretty comfortable or curious Neutral, not opposed to it Nervous or uncomfortable How comfortable do you feel about your sexual and reproductive health overall? Pretty comfortable or curious Neutral Nervous or uncomfortable Do you notice any connection between your menstrual cycle and the moon phases? Yes No I haven't looked into it before Are you interested in syncing your cycle with the moon’s rhythm for deeper womb connection or fertility awareness? Yes, I'd love to learn more Not right now Would you like to explore your natal lunar fertility? - a theory that suggests we may be fertile when the moon returns to the same phase it was in at your birth. Yes, I'd love to learn more Not right now Your assessment has been submitted. Please text me that you have completed this and I should review it shortly. Thank you!