1. Are your periods regular?
   Yes    No
2. Do you usually notice a clear, stretchy vaginal discharge around the middle of your menstrual cycle?
   Yes    No
3. Does your male partner ejaculate during intercourse?
   Yes    No
4. Have you given birth before?
   Yes    No
5. Has your male partner ever impregnated a woman?
   Yes    No
6. Have you and your male partner been having unprotected intercourse around the middle of your menstrual cycle every month for at least 12 months without becoming pregnant?
   Yes    No
7. Is your body temperature elevated about a half degree during the second half of your menstrual cycle compared with the first half?
   Yes    No
8. Are you older than 30?
   Yes    No
9. Have you had more than one miscarriage?
   Yes    No
10. Are your periods nonexistent?
    Yes    No
11. Have you ever had a sexually transmitted disease?
    Yes    No
12. Have you ever undergone surgery in your pelvic region?
    Yes    No
13. Has your male partner ever had an abnormal semen analysis?
    Yes    No
14. Do you or your male partner smoke marijuana?
    Yes    No
15. Did your mother take DES (diethylstilbestrol) while pregnant with you?
    Yes    No
16. Have you ever had an abortion?
    Yes    No
17. Have you or your male partner ever taken chemotherapy or hormone therapy?
    Yes    No
18. Do you have any symptoms of premature menopause (i.e., hot flashes, vaginal dryness)?
    Yes    No

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