PCOS Symptom Assessment

1

How old are you?* This field is required.

2

Are you currently diagnosed with PCOS?* This field is required.

Yes (clinically diagnosed)

Suspected but not diagnosed

Not sure

3

Are you currently trying to conceive?* This field is required.

No

Planning in future

Yes

4

How regular are your periods?* This field is required.

Regular (28–35 days)

Sometimes delayed

Often delayed (40+ days)

Missed periods frequently

5

How many periods do you get per year (approx)?* This field is required.

10–12

6–9

Less than 6

Not sure

6

Do you experience any of the following? (Select all that apply)* This field is required.

Acne (persistent)

Facial hair growth

Hair thinning / hair fall

Weight gain (especially around abdomen)

Dark patches on neck/underarms

None of these

7

Has losing weight been unusually difficult for you?* This field is required.

Yes, very difficult

Somewhat difficult

Not really

8

How would you rate your daily energy levels?* This field is required.

Good

Fluctuating

Often tired

Constant fatigue

9

How much do your symptoms affect your confidence or daily life?* This field is required.

Mild

Moderate

Severe

Very severe

10

If guided by a specialist panel, would you commit to a 3–6 month structured recovery plan?* This field is required.

Yes, I’m ready

Maybe, I need details

Just exploring

11

Your Name* This field is required.

First Name

Last Name

12

Your Email* This field is required.

example@example.com

13

Your WhatsApp Number

Please enter a valid phone number.

14

I understand this assessment does not provide medical diagnosis and agree to be contacted regarding my results.* This field is required.

I agree