Health Assessment

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Thank you for sharing with us

Your response has been received. A PHAF consultant will be in touch if you consented to follow-up. Your information is used solely to support your reproductive well-being.

Section 1 — Basic InformationStep 1 of 5

First Name *

Surname *

Email Address *

Phone Number

Age Range

18–25 (PHAF Target) 26–29 30+

Gender (used to tailor hormonal health insights)

Section 2 — Health Awareness & LiteracyStep 2 of 5

Have you ever had a routine hormonal health check-up? (Prolactin, Testosterone, Progesterone, etc.)

Yes No Not sure Never heard of this before

Genetic carrier status awareness (select any you know your status for)

Thalassemia Tay-Sachs Disease Fragile X Syndrome Down Syndrome

ℹ️ Early understanding of chromosomal risks is vital at any age, not just for older parents.

How much does daily stress or anxiety affect your physical health? (1 = not at all, 10 = significantly)

Section 3 — Your Journey & GoalsStep 3 of 5

What brings you to us today? (select all that apply)

General health literacy and self-knowledge Planning for a future family (Preconception Care) Support for reproductive challenges (Fertility, Hormonal Imbalance) Mental health or reproductive psychology support Genetic counselling education

Is there a specific concern you’d like to share in a safe space? (optional)

Section 4 — Support PreferencesStep 4 of 5

How would you like to engage with our programmes? (select all that apply)

Free health fairs & screenings One-on-one counselling Educational workshops & outreach Digital health campaigns & resources

Section 5 — Privacy & ConsentStep 5 of 5

Your privacy is our priority. All information shared here is strictly confidential and used solely to provide you with informed choices for your reproductive well-being and productive quality of life.

I consent to being contacted by a PHAF consultant for further guidance based on my responses.

Your response is saved securely. We respect your time and your story.

Preconception & Reproductive
Health Assessment

Thank you for sharing with us

PHAF Health Assistant

Preconception & ReproductiveHealth Assessment

Thank you for sharing with us

PHAF Health Assistant

PHAF Health Assistant

Preconception & Reproductive
Health Assessment