Polycystic Ovary Syndrome (Pcos) Questionnaire : PCOS is a hormone imbalance that affects how a woman’s ovaries work. PCOS stands for polycystic ovarian syndrome and is the most common hormone disorder in women of reproductive age. PCOS can affect a woman’s menstrual cycle, fertility, hormones, and appearance. This article will answer some of the most commonly asked questions about PCOS.


Polycystic Ovary Syndrome (PCOS) Questionnaire for Women
Instructions:




This questionnaire is designed to help identify potential symptoms and risk factors associated with PCOS. It is not a diagnostic tool, but rather a means to gather information that may be useful for discussion with your healthcare provider. Please answer all questions honestly and to the best of your ability.

Personal Information:
Age: __ years
Height: __ cm / __ inches
Weight: __ kg / __ lbs

Menstrual History:

At what age did you have your first menstrual period? __ years

How would you describe your menstrual cycles?

[_] Regular (every 21-35 days)
[_] Irregular (unpredictable or varying cycle lengths)
[_] Infrequent (less than 8 periods per year)
[_] Absent (no periods for 3 months or more)

On average, how many days does your menstrual flow last? __ days

Symptoms:

Do you experience any of the following symptoms? (Check all that apply)

[_] Excess facial or body hair growth
[_] Acne
[_] Male-pattern baldness or thinning hair
[_] Weight gain or difficulty losing weight
[_] Darkening of skin in body creases (e.g., neck, groin, under breasts)
[_] Skin tags (small flaps of excess skin)
[_] Mood swings or depression
[_] Fatigue
[_] Pelvic pain

On a scale of 1-5, how severe would you rate your symptoms overall?
(1 = Very mild, 5 = Very severe)

1 [] 2 [] 3 [] 4 [] 5 [_]

Fertility and Pregnancy:

Have you ever tried to conceive?

[_] Yes
[_] No

If yes, have you experienced difficulty getting pregnant?

[_] Yes
[_] No
[_] Not applicable

Have you ever been diagnosed with:

[_] Gestational diabetes
[_] Pregnancy-induced hypertension
[_] Miscarriage
[_] None of the above
Medical History:

Have you ever been diagnosed with any of the following conditions? (Check all that apply)

[_] Type 2 diabetes
[_] Insulin resistance
[_] High blood pressure
[_] High cholesterol
[_] Sleep apnea
[_] Anxiety or depression
[_] Eating disorders

Is there a family history of PCOS?

[_] Yes
[_] No
[_] Unsure

Are you currently taking any medications or supplements? If yes, please list them:

Lifestyle:

How would you rate your overall diet?

[_] Very healthy
[_] Somewhat healthy
[_] Average
[_] Somewhat unhealthy
[_] Very unhealthy

On average, how many days per week do you engage in physical activity for at least 30 minutes?
0 [] 1 [] 2 [] 3 [] 4 [] 5 [] 6 [] 7 []

How would you rate your stress levels on a typical day?
(1 = Very low, 5 = Very high)

1 [] 2 [] 3 [] 4 [] 5 [_]

Do you smoke?

[_] Yes
[_] No
[_] Former smoker



What concerns you most about your health or symptoms?

What steps, if any, have you taken to manage your symptoms or improve your health?

Thank you for completing this questionnaire. Please share your responses with your healthcare provider to discuss any concerns and potential next steps in your health management.


Polycystic Ovary Syndrome (Pcos) Questionnaire

Polycystic ovarian syndrome (PCOS) is a common health condition that can affect women of reproductive age. It can cause a wide range of symptoms, including irregular periods, excess hair growth, acne and weight gain. 

PCOS can also affect a woman’s fertility and her chances of getting pregnant. However, there are a number of treatment options available, and with the right care and support, many women with PCOS can have a successful pregnancy. 

Polycystic ovary syndrome (PCOS) is a health condition caused by a problem with the way your ovaries work. It's one of the most common female health problems. PCOS affects how a woman's ovaries work. Ovaries make eggs and female hormones. Symptoms can include irregular periods, unwanted hair growth, acne, and weight gain. You may hear PCOS called Stein-Leventhal syndrome. This is the old name for PCOS. PCOS can be mild, moderate, or severe. It can also change over time. Many women with PCOS have problems getting pregnant (infertility). But, many with PCOS can have children without help. Some women with PCOS need treatment to lessen their symptoms and help them get pregnant.