Name Email Phone Age: [select* age "Select" "20-25 (5 points)" "26-30 (4 points)" "31-35 (3 points)" "36-40 (2 points)" "More than 40 (1 point)" id:age] Length of Menstrual Cycles: [select* menstrualCycle "Select" "26 days - 34 days Regular (5 points)" "35 – 40 days Regular (4 points)" "20 days to 25 days Short (3 points)" "More than 40 days (2 points)" "Gets periods only with Tablets (1 point)" id:menstrualCycle] Prior Pregnancies: [select* priorPregnancies "Select" "1 or more live births (5 points)" "Voluntary done termination of Pregnancy (4 points)" "1 miscarriage (3 points)" "More than 1 miscarriage (2 points)" "No pregnancy even after trying for 1 year (1 point)" id:priorPregnancies] Frequency of Intercourse: [select* frequencyIntercourse "Select" "3-4 times /week (5 points)" "1-2 times a week (4 points)" "Once in 10-15 days (3 points)" "Once in a month (2 points)" "Difficulty in intercourse (1 point)" id:frequencyIntercourse] Age of Menopause of Mother: [select* motherMenopauseAge "Select" "50 years or above (5 points)" "46 years to 49 years (4 points)" "40 years to 45 years (3 points)" "36 to 40 years (2 points)" "Less than 36 years (1 point)" id:motherMenopauseAge]
