Cycle & Hormone Panel Assessment

Which age group are you in?(Required)

What’s the main reason you’re looking into your hormones?(Required)

My periods are irregular or I’ve missed some

My periods are heavy or painful

PMS or mood changes around my cycle

I’m trying to get pregnant, or planning to

Acne, unwanted hair growth, or other signs of hormone imbalance

Perimenopause symptoms

I want a baseline picture of my hormones

Have you had hormone blood work in the last 12 months?(Required)

Yes

No

Not sure

Were any of those results flagged as outside the normal range?(Required)

Yes

No

I don’t know

What would you like to happen once your results are in?(Required)

Understand what’s going on with my hormones

Talk to a provider about treatment options

Plan for a pregnancy

I’m not sure yet

Which state do you live in?(Required)

To verify eligibility, what’s your date of birth?(Required)

Where should your provider reach you?

We’ll email you about your kit, your results and your next steps.

Email(Required)

What was your sex assigned at birth?(Required)

Female

Male

Intersex

Prefer not to say

Do any of these apply to you right now?(Required)

I’m pregnant

I might be pregnant

I’m breastfeeding

I gave birth or had a pregnancy loss in the last 12 months

None of these

Are you trying to get pregnant?(Required)

Yes, right now

Planning to in the next 12 months

No

Not sure

How long have you been trying?(Required)

Less than 6 months

6–12 months

More than 12 months

How many miscarriages have you had?(Required)

None

1

2 or more

Prefer not to say

How would you describe your periods over the last 12 months?(Required)

Regular: they come about the same time each month

Irregular: they’re hard to predict

I haven’t had a period in 3 months or more

I haven’t had a period in 12 months or more

I don’t have periods because of surgery or medical treatment

My bleeding is controlled by birth control or an IUD

Have you had any bleeding or spotting since your periods stopped?(Required)

Yes

No

How many days is your usual cycle?(Required)

Count from the first day of one period to the first day of the next.

Fewer than 21

21–35

More than 35

It varies by more than 7 days

I’m not sure

When did your most recent period start?(Required)

An approximate date is fine.

How many days does your period usually last?(Required)

Fewer than 3

3–7

More than 7

How heavy is your flow on your heaviest day?(Required)

Light

Moderate

Heavy: I soak a pad or tampon every 1–2 hours, or pass clots larger than a quarter

Do you have any of these with your cycle?(Required)

Bleeding or spotting between periods

Bleeding after sex

Cramps severe enough to stop my normal activities

Pain during sex

Mood symptoms in the week before my period that affect work or relationships

None of these

Will you be able to collect your kit on two days of your cycle?(Required)

Once between days 2–5, and again about a week before your next period.

Yes

Probably

I’m not sure I’ll know when those days are

In the last 3 months, have you noticed any of these?(Required)

Acne, especially along the jaw or chin

Unwanted hair on the face, chest or belly

Thinning hair on the scalp

Weight gain, or trouble losing weight

Breast tenderness

Milky discharge from the nipples when not breastfeeding

None of these

And any of these?(Required)

Tiredness that doesn’t improve with rest

Feeling cold, dry skin, or constipation

Racing heart, feeling hot, or shaky hands

Hot flashes or night sweats

Low sex drive

Trouble sleeping

Mood swings, anxiety or irritability

Headaches with changes in your vision

None of these

Overall, how much do these symptoms affect your daily life?(Required)

Not at all

A little

Moderately

A lot

Some of what you’ve shared should be checked in person, as well as through your at-home kit.(Required)

Your provider will talk you through next steps.

I understand

Which birth control are you using now?(Required)

If you use more than one, choose the hormonal one.

Combined pill

Progestin-only pill (“mini-pill”)

Hormonal IUD (Mirena, Kyleena, Liletta, Skyla)

Copper IUD

Implant (Nexplanon)

Injection (Depo-Provera)

Patch or ring

Non-hormonal only (condoms, fertility awareness, tubal ligation, partner vasectomy)

None

When did you last use hormonal birth control?(Required)

Never

More than 12 months ago

3–12 months ago

1–3 months ago

Less than a month ago

In the last 3 months, have you taken any of these?(Required)

Estrogen (pill, patch, gel or cream)

Progesterone or a progestin, not as birth control

Testosterone

Fertility medication (clomiphene, letrozole, or injections)

Thyroid medication

Metformin

Spironolactone

Steroid tablets or injections (prednisone, cortisone)

None of these

Do you take any of these medications?(Required)

Antipsychotic medication

Anti-nausea medication (metoclopramide, domperidone)

Opioid pain medication

Antidepressants (SSRIs or SNRIs)

Seizure medication

GLP-1 weight-loss medication (semaglutide, tirzepatide)

None of these

Do you take any of these supplements?(Required)

Biotin can throw off hormone test results. Your provider may ask you to stop it for 3 days before you collect your sample.

Biotin, or a hair, skin and nails supplement

DHEA

Vitex (chasteberry)

Maca, black cohosh, or another herbal hormone supplement

Inositol

None of these

Are you taking any other medications you haven’t mentioned?(Required)

Yes

No

Have you ever had any of these?(Required)

A blood clot (DVT or pulmonary embolism)

A stroke or heart attack

Migraine with aura

High blood pressure

Breast, ovarian or uterine cancer

Liver disease

Kidney disease

None of these

Have you had any of these surgeries or treatments?(Required)

Hysterectomy (uterus removed)

One ovary removed

Both ovaries removed

Endometrial ablation

Tubal ligation

Surgery on your ovaries (cysts or endometriosis)

Chemotherapy or radiation to the pelvis

None of these

Has anyone in your immediate family had any of these?(Required)

PCOS

Menopause before age 45

Thyroid disease

Type 2 diabetes

Breast or ovarian cancer

Blood clots

None of these

In the last 6 months, have any of these applied to you?(Required)

Lost more than 10 lb

Gained more than 10 lb

Exercised hard for more than 7 hours a week

Followed a very restrictive or low-calorie diet

Been under major stress

Worked night or rotating shifts

None of these

How tall are you?

Height — feet(Required)

Please enter a number from 3 to 8.

Height — inches(Required)

Please enter a number from 0 to 11.

What’s your current weight?

Current weight(Required)

Please enter a number from 50 to 800.

Do you smoke or use nicotine?(Required)

Yes, daily

Yes, sometimes

I used to, but quit

Never

Do you have any medication allergies?(Required)

Yes

No

What are you allergic to?(Required)

Antibiotics

Hormone medications

Pain relievers (NSAIDs such as ibuprofen)

Sulfa drugs

Latex or adhesives

Something else

Your kit uses a small finger-prick blood sample. How do you feel about collecting it yourself?(Required)

Comfortable

Nervous, but I can do it

I’ve fainted at the sight of blood before

Is there anything else you want your provider to know?(Required)

No, I’ve shared everything relevant

Yes, there’s something I want to raise with my provider