HA Assessment

Dietetic Assessment for HA

Please fill out this assessment form as best you can; however do not worry if you do not have all of the information requested.

At the time of diagnosis

Date diagnosed with HA

Examination / Tests performed at diagnosis of HA

Physical ExamVaginal Ultrasound (sonography)MRIBone Scan (DXA scan)Progesterone Challenge

Bloods at diagnosis (if known)

* if clinical hyperandrogenism

Attach blood results file (8mb max)

Anthropometrics at diagnosis


Physical activity at diagnosis

Please note down your previous planned and unplanned physical activity, specifying duration. 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.

*Low: able to breathe and talk normally
Moderate: feels somewhat hard. Here are clues that your exercise intensity is at a moderate level:
• Your breathing quickens, but you're not out of breath.
• You develop a light sweat after about 10 minutes of activity.
• You can carry on a conversation, but you can't sing.
Vigorous: feels challenging. Here are clues that your exercise intensity is at a vigorous level:
• Your breathing is deep and rapid.
• You develop a sweat after only a few minutes of activity.
• You can't say more than a few words without pausing for breath.

Subjective assessment of stress levels at diagnosis

How high were your levels of stress at the time of diagnosis with HA? (0- no stress at all; 10- very high levels of stress, impacting on work/relationships)

Medications

What medications/ supplements were you taking at the time of diagnosis?

Diet

How would you describe your dietary intake at the time of diagnosis? Were you restricting any foods/ food groups or calories?

Post Diagnosis

Anthropometrics

Please record your recent

Bloods

Have you had any recent blood tests? Please attach the report, if available. 8mb max file size

Medications

What medications/ supplements are you currently taking?

Other medical conditions

What (if any) other medical conditions do you currently have?

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.

Subjective assessment of stress levels

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

The Perceived Stress Scale

Although some of the questions are similar, there are differences between them and you should treat each one as a separate question. The best approach is to answer fairly quickly. That is, don't try to count up the number of times you felt a particular way; rather indicate the alternative that seems like a reasonable estimate.
For each question choose from the following alternatives:
0 – never 1 - almost never 2 – sometimes 3 - fairly often 4 - very often

1. In the last month, how often have you been upset because of something that happened unexpectedly?
2. In the last month, how often have you felt that you were unable to control the important things in your life?
3. In the last month, how often have you felt nervous and stressed?
4. In the last month, how often have you felt confident about your ability to handle your personal problems?
5. In the last month, how often have you felt that things were going your way?
6. In the last month, how often have you found that you could not cope with all the things that you had to do?
7. In the last month, how often have you been able to control irritations in your life?
8. In the last month, how often have you felt that you were on top of things?
9. In the last month, how often have you been angered because of things that happened that were outside of your control?
10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

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.


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