PCOS Assessment form

PCOS Self Assessment
Learn to reverse your PCOS

The following assessment gives us an indication of whether you may have Polycystic ovaries (PCOS). For a thorough assessment and natural treatment plan to support you in reversing your PCOS, do contact us and we can arrange a face-to-face or teleconference consultation.
Name*

First NameLast Name
Email*
Phone
Your age category*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Have you been diagnosed with any of the following? Please select any of the options below which apply to your current health situation*

PCOSOvarian CystsEndometriosisFibroidsMenopauseThyroid disordersInsulin resistance/hypoglycaemiaAdrenal exhaustionNONE apply to me
Do you experience any of the following symptoms? Please select any which apply to you*

Irregular menstrual cycles (periods)Painful periodsHeavy or prolonged menstrual bleedingBreast tendernessAcneIncreased facial or body hair growth (hirsutism)Thinning hair or hair loss on your scalpSlow metabolismDifficulty getting pregnantUnexplained weight gain or difficulty losing weightMood swingsSugar cravingsA history of high blood sugar or diabetes in your familyOften feel fatigued or have low energy levelsNONE apply to meDiagnosed with a thyroid condition
My Diet: Please select any which apply to you

I eat far too many carbs - bread, pasta, potatoesI crave sugarI eat less that 5 portions of vegetables a day (portion is about a handful)I eat takeaways regularlyI do not know how to cook wellI often binge eatI am always on a diet
Hormone balance: Please select any which apply to you right now *

My cycle is 35 days or longer for significant lengths of yime/alwaysA scan has shown polyscystic ovariesI have a high LH to FSH on my blood testsI ovulate late in my cycle (day 18 or later)
Do you have androgen excess? Please select any which apply to you right now*

Hirsutism: excess, coarse hair around chin, abdomen, face or chestAcne around jawline, back and chinHairlossDeep voiceHigh Testosterone, free testosterone, DHEA on your blood tests
Root Causes of PCOS
ROOT CAUSE 1: Insulin resistance. Please select any which apply*

Unexplained weight gainIf I dont eat regularly I can get the shakes, diziness, hangryWeight mainly around abdomenMembers of my family have diabetesStruggle to lose weightSkin tagsCrave carbs like potatoes and breadFatty liverDark thick velvety skin in body folds around neck, groin or armpits (Acanthosis nigricans)NONE apply to me
ROOT CAUSE 2: Post pill PCOS. Please select any which apply*

My symptoms started after coming off the contraceptive pillSymptoms were fine (eg acne) but worsened about 6 months after stoppingthe oral contraceptive pillNONE apply to me
ROOT CAUSE 3: Inflammation. Please select any which apply*

Puffiness & BloatingConstantly tired or lethargicAnxious depressionFoggy thinkingRed flushed faceOngoing digestive problems (eg reflux, diverticulitis, diarrhea)Skin conditions such as exzema, rashes, rosacea, psoriasisAllergiesAsthmaPain in my bodyHeadachesNONE apply to me
SYMPTOMS GROUP 4: Stress and anxiety. Please select any which apply*

I have been extremely stressed in the past yearsI have panic attacksI am depressedI need caffeine or other stimulants to get me through the dayI am anxiousI have high or low blood pressureI suffer from palpitationsI have low libidoI work too hard and do not take breaksMy energy slumps mid afteroonI have insomniaI have a high cortisol or DHEA-S reading on my blood testsI get a second wind at nightNONE apply to me
*Please note, if you selected 2 or more boxes in any of the four ROOT CAUSE groups you may have PCOS. Please submit your questionnaire at the bottom of this page and a Sheena Hendon Health qualified Naturopath and Nutritionist will contact you soon to inform you of options for further functional testing and ways to reverse PCOS.
For more information on the functional treatment of PCOS please read this article https://sheenahendonhealth.co.nz/think-you-have-pcos-steps-for-reversing-symptoms-both-holistically-and-naturally/ or https://sheenahendonhealth.co.nz/hormone-imbalance-it-may-be-triggered-by-insulin-resistance/
Please list below any medication you are currently taking including contraceptives
Please list below any health supplements you are currently taking
Please feel free to provide any other information you feel may assist us in helping you further
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PCOS Self Assessment Learn to reverse your PCOS

Root Causes of PCOS

PCOS Self Assessment
Learn to reverse your PCOS