Part 1: Clinical Information

    When were you diagnosed with PCOS?

    Do you have irregular or absent periods?

    yesno

    If you have irregular periods, please could you describe their pattern (if any) and associated symptoms?

    Do you have excessive body/facial hair?

    yesno

    Do you suffer with acne?

    yesno

    Could you please list any medications that have been prescribed for the management of PCOS?

    Are you taking any over the counter medications or supplements?

    yesno

    Do you have any other medical conditions?

    yesno

    Have you had any recent blood tests?

    yesno

    Attach blood results file (8mb max)

    What are your goals?

    Part 2: Dietary & Lifestyle Assessment

    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 of unintentional physical activity include walking or cycling to work or shops, housework and gardening.

    Diet

    Please record your usual day of eating. Please include all food and drinks. It would be helpful to understand what you usually consume at each meal and snack time.

    If you keep a food diary or use an app for this, you can upload it here, if you wish.(8mb max)

    Allergies & intolerances

    Your relationship with food.

    Please tick any of the below if it applies to you:

    I usually describe a day of eating as either good or badIf I eat dessert, I make plans to exercise moreOnce I eat a forbidden food, I think, I blew it, and then I eat whatever I want, 
usually in large quantitiesI feel guilty if I don’t do my usual levels of exerciseIf 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 levelsI will not let myself eat a particular snack/ meal if it exceeds a certain number 
of caloriesI weigh myself frequently

    Alcohol

    How many units of alcohol do you drink per week? If you are unsure, please use this link to help you Drink Aware

    Smoking

    Do you smoke?

    yesno

    Thank you for taking time to complete this assessment questionnaire. The assessment will help me decide what we may need to explore in a greater detail and what changes would make the biggest difference. We will build on this during the initial appointment and you will have an opportunity to expand on any of the above and also tell me about anything else that is important to you and how you would like to move forward.

    I have read and accept the privacy statement


    Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.