PCOS Initial Appointment Assessment

Client Assessment Form

Thank you for taking time to complete this assessment questionnaire. The assessment will help me decide what we may need to explore in greater detail and what changes would make the biggest difference to achieving your goals.

Basic Info

Do you have a recent blood test?YesNo

Medications & Supplements

Are you currently taking any medications or supplements?YesNo

Current physical activity levels

Please note down your usual planned and unplanned physical activity. Record intensity levels using L for low intensity, M for moderate & V for vigorous intensity. Examples include walking or cycling to work, housework, and gardening.

Stress Levels

How high are your levels of stress at present? (0 = no stress; 10 = very high stress impacting work/relationships)

Diet Diary

Are you avoiding any food or drinks? YesNo

Allergies

Do you have any diagnosed allergies?YesNo

Your Relationship with Food

I usually describe a day of eating as either good or bad.

If I eat dessert, I make plans to exercise more.

Once I eat a forbidden food, I think I blew it, and then I eat whatever I want, usually in large quantities.

I feel guilty if I don’t do my usual levels of exercise.

If I am planning to go out for dinner/drinks, I cut back how much I eat during the day, regardless of my hunger and fullness levels.

I will not let myself eat a particular snack/meal if it exceeds a certain number of calories.

I weigh myself frequently.

Alcohol: How many units of alcohol do you drink per week? (If you are unsure, please visit drinkaware.co.uk)

Smoking

Do you smoke?YesNo

Your Goals

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