MyAdvo Intake Form

Take a few minutes to tell us about yourself and your health journey.

All information remains confidential and secure.

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number

Please enter a valid phone number.

Zip code of your current place of residence:* This field is required.

Which of these best describes your current gender identity?* This field is required.

Cisgender female/woman

Cisgender male/man

Genderqueer, gender non-binary, or gender fluid

Transgender female/woman

Transgender male/man

A gender not listed here

How would you describe yourself? (Please select all that apply)* This field is required.

White

Hispanic, Latino or Spanish origin

Black

Asian

American Indian or Alaska Native

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

Other

Which of these best describes your current sexual orientation?* This field is required.

Asexual

Bisexual

Gay/Lesbian

Heterosexual/Straight

Pansexual

Queer

A sexual orientation not listed here

What is your marital status?* This field is required.

Single (never married)

Married, or in a domestic partnership

Widowed

Divorced

Separated

Other

What is your current employment status?

Employed full time (40 or more hours per week)

Employed part time (up to 39 hours per week)

Not employed, looking for work

Not employed, NOT looking for work

Student

Retired

Homemaker

Self-employed

Disabled, not able to work

Which of the following do you experience? (Please select all that apply.)* This field is required.

Adenomyosis

Endometriosis

Fibroids

PCOS

Other

Which conditions have you had an official diagnosis for? (Please select all that apply)* This field is required.

Fibroids

Adenomyosis

Endometriosis

PCOS

Other

Which of the following best describes your current stage of medical care?* This field is required.

Newly Diagnosed: Just beginning to explore treatment options.

Diagnosis without active follow-up: Diagnosed over a year ago but currently not pursuing treatment.

Awaiting treatment: Treatment plan established, awaiting start.

Undergoing treatment: Receiving treatments such as hormonal therapy, pain management, medication, or lifestyle intervention.

Pre-Surgery: Scheduled for surgery and preparing for the procedure.

Post-Surgery: Currently in the recovery phase following surgery.

Managing recurrence: Addressing symptoms or disease recurrence post-treatment.

Chronic Management: Actively managing ongoing treatment and management of symptoms.

Fertility Planning: Seeking treatment specifically for fertility concerns.

Other

What treatments have you undergone? (Please select all that apply)* This field is required.

Surgery

Hormonal Birth Control

Prescribed Medication

Alternative Medicine

Pelvic Floor Therapy

Other

How would you describe your current life stage?

What doctors and/or specialists make up your current care team? (Please select all that apply)* This field is required.

OB/GYN

Obstetritian

Primary Care Provider (PCP)

Nutrionist / Dietitian

Functional / Integrative Doctor

Gastroenterologist

Reproductive Endocrinologist / Fertility Specialist

Acupuncturist

Therapist

Psychiatrist

Pelvic Floor Therapist

Massage Therapist

Other

Are there any providers you recommend adding to our specialist directory to help others find care?* This field is required.

YESNO

Please add their name(s), specialties, and city. * This field is required.

How well do you understand your hormonal health? (Please rank with 1 being do not understand at all and 5 being an expert)* This field is required.

What outcome are you looking for help with? (Please select all that apply)* This field is required.

Learning about my condition

Trying to conceive

Exploring treatments

Looking for a doctor

Getting a diagnosis

Managing symptoms

Community Support

Other

How urgent do you feel achieving this outcome is? (Please rank with 1 being not urgent and 5 being extremely urgent)* This field is required.

This community works because everyone is willing to ask for help and share their experiences with an open-minded mindset, honoring everyone's personal values concerning their care. Do you promise to respectfully offer support to fellow members when you can and ask for help when you need?* This field is required.

How did you hear about MyAdvo? (Please select all that apply)* This field is required.

Instagram

Facebook

TikTok

Friend / Family

Work

Healthcare Provider

Other

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