Your age: 

On average, how many days is it from the first day of your period to the first day of your next period?

Enter the first day of your last normal period: 
Enter the day you think you conceived: 

Did you have additional acts of intercourse during that month? 
YES  NO 

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Have you experienced any of the following? (check all that apply):  
Nausea or Vomiting 
Fatigue or a need for Extra Sleep 
Weight Gain or Feeling Bloated 
Changes in Appetite 
Frequent Urination   
Sore or Tender Breasts 
Odd Sensations in the Abdomen 
A Positive Pregnancy Test 
Sharp Pain in Abdomen/Side 

Are you… (check all that apply): 
Under Unusual Stress Lately? 
Exercising More than Usual? 
Underweight for Your Height? 

What birth control method were you using when you think you conceived?: 
None (trying to get pregnant)