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PCOS Made Manageable Intake Assessment

Please complete this assessment to share your PCOS history, symptoms, and goals.

Make sure you have your "before" photos taken before beginning.

"Before" photos are not mandatory but they're very helpful for staying accountable and gauging your weight loss progress.

Click the button below to start.

Start

Section One

Personal and Contact Information

Question 2 of 42

Full Name:

Question 3 of 42

Age:

Question 4 of 42

Email:

Question 5 of 42

Phone Number:

Question 6 of 42

Current Location (City, State/Country):

Question 7 of 42

Instagram Username (if applicable):

Before Photos

Please upload your "before" photos.

Include a front, back & side view. Have someone take the photos for you or use a self-timer.

 

Wear a bikini, a short pair of shorts or whatever you're comfortable in.

 

Please note: these will never be shared or posted without permission.

Question 9 of 42

Upload your front view.

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Question 10 of 42

Upload your side view.

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Question 11 of 42

Upload your back view.

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Section Two

Medical Background

Question 13 of 42

If you were diagnosed with PCOS, when was the diagnosis?

Question 14 of 42

Describe your experience with your healthcare provider(s):
(e.g., How supportive/informative were they? Did they provide a clear treatment path?)

Question 15 of 42

Have you experienced any of the following symptoms? (Check all that apply)

(Select all that apply)
A

Irregular or absent periods

B

Heavy or painful periods

C

Acne

D

Excessive hair growth (hirsutism)

E

Hair loss

F

Weight gain, difficulty losing weight

G

Fatigue

H

Mood swings

I

Low libido

J

Difficulty with focus and concentration

K

Difficulty sleeping

L

Insulin resistance or prediabetes

M

High cholesterol or triglyceride levels

N

High blood pressure

O

Digestive issues (e.g., bloating, constipation)

P

Other

Question 16 of 42

Are you currently on any medications for PCOS or other conditions?

If yes, please list medications and dosages:

Section Three

Supplement Use

Question 18 of 42

Are you currently using any supplements?

If yes, please list supplements, dosages, and frequency:

Question 19 of 42

Have you taken any supplements specifically for PCOS before?

If yes, what were they, and did you find them effective?

Section Four

Lifestyle and Routine

Question 21 of 42

Describe your typical daily schedule (work, school, etc.):

Question 22 of 42

How would you rate your current sleep quality?

Very good, Good, Fair, Poor, Very poor

Question 23 of 42

On average, how many hours do you sleep each night?

Question 24 of 42

How would you describe your stress levels?

Low, Moderate, High, Extremely high

Question 25 of 42

How do you usually cope with stress?

(e.g., Exercise, Meditation, Talking to friends, etc.)

Section Five

Current Nutrition and Exercise

Question 27 of 42

Describe your current nutrition plan or typical diet:

(e.g., vegetarian, low-carb, balanced, high in processed foods, etc.)

Question 28 of 42

What are your biggest struggles with food/nutrition, if any?

Question 29 of 42

Do you currently have any dietary restrictions or allergies?

Question 30 of 42

Type of training you're doing now & frequency:

Question 31 of 42

How many times per week would you like to train?

What are your ideal rest days?

Question 32 of 42

Do you have access to a full gym? If not, please list your available equipment.

Question 33 of 42

Do you have any injuries?

Section Six

Goals and Expectations

Question 35 of 42

What are you hoping to achieve from this program? (Check all that apply)

(Select all that apply)
A

Symptom management

B

Weight loss

C

Improved energy levels

D

Improved sleep

E

Hormone balance

F

Pregnancy/fertility support

G

Overall wellness

H

Other

Question 36 of 42

On a scale of 1-10, how important is it for you to achieve these goals?

Question 37 of 42

If you veer off course, are you more likely to:

(Select all that apply)
A

Get back up and try again

B

Ask for help

C

Stay quiet and continue off course

Question 38 of 42

If you find yourself eating emotionally (you’re not actually hungry), can you identify your triggers?

For example: boredom, stressed, having an overall bad day, habit, etc.

Question 39 of 42

What coaching style do you respond to best?

(Select all that apply)
A

Tough love and constructive criticism

B

Empathy and understanding

C

Encourage strict adherence

D

Provide motivation without constructive criticism

E

I just want someone to listen

Section Seven

Additional Insights

Question 41 of 42

Is there anything else you’d like me to know about your PCOS journey?

Question 42 of 42

Is there any support you feel is missing in your current approach to managing PCOS, if applicable?

Confirm and Submit