PCOS Questionnaire

"I learned that if I didn't respect and care for my body...I'd have no place to live." ~~After the Diet client

After the Diet™

Helping Humans Overcome Eating Problems

Ayudando a Personas con Problemas Alimentarios

We would like to know more about our website visitors, so we can develop products and services that are useful to them. If you would like to help us, below you will find a questionnaire with just a few questions that we would like you to answer. We are not asking for your name or identifying information, because we want to be sure you feel that we can in no way use this information or distribute information about you. We mostly wish to better understand PCOS, and the best way to do that is to go straight to the source--to women just like you!

Which of the following symptoms of PCOS are most bothersome for you?
infertility
weight gain
carbohydrate cravings
mood swings
depression
anxiety
insulin resistance
facial hair
losing hair
acne
Which of the following treatments for PCOS has been recommended for you to try?
low carbohydrate diet
nondiet/healthy eating/reduce bingeing
exercise
insulin sensitizing medicaiton
birth control pills
antidepressant medication
mood stabilizing medication (for bipolar disorder)
acne medication
medication for my facial hair
psychological counseling
acupuncture
other
Please describe what treatments you have been recommended if you listed "other"
Which of the following treatments for PCOS did you actually try?
low carbohydrate diet
nondiet/healthy eating/reduce binges
exercise
insulin sensitizing medication
birth control pills
antidepressant medication
mood stabilizing medication (for bipolar disorder)
acne medication
medication for my facial hair
psychological counseling
acupuncture
other
Please list what treatments you tried if you listed "other"
Which of the following treatments that you tried did you feel were helpful to you?
low carbohydrate diet
nondiet/healthy eating/reduce binges
exercise
insulin sensitizing medicaiton
birth control pills
antidepressant medication
mood stablizing medication (for bipolar disorder)
acne medication
medication for my facial hair
psychological counseling
acupuncture
other
Please describe if you chose "other"
Have you ever had any of the following medical problems (check all that apply):
respiratory allergies
irritable bowel syndrome
asthma
food allergies
eczema
insomnia
restless legs
eating during the night
chronic fatigue syndrome
fibromyalgia
panic attacks
PMS
What prescription medications are you currently taking?
Please list any over the counter medications (asthma, allergy, pain medications, for example) that you have taken in the last week
Of the over the counter medications that you took, please list any you take on a regular basis (more than twice a week)

Copyright © 2004 [After the Diet Network]. All rights reserved. Revised: 07/06/07

Copyright © 2004 [After the Diet Network]. All rights reserved.
Revised: 07/06/07