PCOS Initial Appointment Assessment

Are you currently taking any medications or supplements?

Yes No

If so, what medications / supplements are you currently taking?

Other medical conditions

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.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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?

Yes No

If so, which food or drinks are you avoiding? (Please record the food/drinks and the reason)

Do you have any diagnosed allergies?

Yes No

If so, what were you diagnosed with?

When were you diagnosed with PCOS?

Do you have irregular or absent periods?

Yes No

If you have irregular periods, please describe their pattern and any associated symptoms.

Do you have excessive body or facial hair?

Yes No

If yes, please provide additional details (e.g., areas affected, severity).

Do you suffer from acne?

Yes No

If yes, please provide additional details (e.g., severity, areas affected).

Could you please list any medications prescribed for the management of PCOS, including doses if possible?

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)

Do you smoke?

Yes No

Your Goals

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