PCOS Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Please enter your email, so we can follow up with you.Marital statusMarriedSingleDivorcedWidowAre you going through stress phase?Have you ever been sick since puberty?Do you have acne of face?YesNoDo have acne of chest or back?YesNoDo you have excessive hair loss?YesNoHave problem staying at your ideal weight?YesNoConcerned about being over-weight?YesNoAre you frustrated in trying to lose weight?YesTo some extentNeverWhere do think you need to lose weight?Mid-section/Upper bodyThighs or rear endAll of the aboveHow old were you when you first started menstruation?Your menstruation is heavy?YesNoDo you irregular Menstruation?YesNoDo you get cramps during menstruation?YesNoAlwaysDo you have abdominal bloating during menstruation?YesSometimesAlwaysNeverDo you get any Headaches or nausea during menstruation?YesNoNeverSometimesAlwaysMy hair in general are?NormalThickFineGrowth of visible hair on the face?YesNoGrowth of visible hair on the Upper lip?YesNoI am self-conscious as a result of PCOS?YesNoI am self-conscious as a result of PCOS?YesNoI have low self esteem as result of PCOS?YesNoNeverAlwaysI feel depressed as result of PCOS?SometimeAlwaysNeverMy mood fluctuations are result of my PCOS?SignificantlyRarelyAlwaysNeverDo you have any of the following?Low energyFearsPhobia or fearsAnxietyPanic attacksAll of the aboveDid your OB/GYN told about any fertility problem?YesNoAre you worried about your fertility problem?Yes alwaysNot at allYes to some extentDo you feel sad because of the fertility issues?YesNoAlwaysAre you trying to get pregnant?YesNoWhat kind of treatment you have taken in past?No treatmentHomeopathicAyurvedicConventional treatmentIf one of the above? How long?1-2 months2-6 months6 months – year or longerHave you ever been on Birth Control Pills as a part of treatment?YesNoWhat kind treatment were you on? Please explainHow long?Any message? PhoneSubmit
