PCOD Screening

• Demographic Details
  Full Name

  Enter First name

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  • Mr.
  • Ms./Mrs.
  • Master
  • Baby

  Mr. Ms./Mrs. Master Baby

  Age *

  Please Select Date of Birth

  Age must be greater than 0 and less than 125 Years

  Months must be less than 12

  Days must be less than 31

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• PCOD Screening
  Do you have immediate family history of any of the adjacent diseases? *  

  Please Enter Do you have immediate family history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease Stroke Lipid disorders (cholesterol) Thyroid disorders Pcod/pcos Others None

  Do you have history of any of the adjacent diseases? *

  Please Enter Do you have history of any of the adjacent diseases?

  Pcod/pcos Diabetes Hypertension Heart disease/stroke Lipid disorders (cholesterol) Thyroid disorders Nutritional deficiencies (vitamin b12/d/calcium/iron) Others None

  Do you have irregular period cycles? *

  Please Enter Do you have irregular period cycles?

  Yes No

  Do you have excessive facial hair growth? *

  Please Enter Do you have excessive facial hair growth?

  Yes No

  Do you have frequent acne? *

  Please Enter Do you have frequent acne?

  Yes No

  Have you experienced nipple discharge when neither pregnant nor breast feeding? *

  Please Enter Have you experienced nipple discharge when neither pregnant nor breast feeding?

  Yes No

  How many minutes in a week do you exercise? *

  Please Enter How many minutes in a week do you exercise?

  What does your diet predominantly contain? *

  Please Enter What does your diet predominantly contain?

  Fruits and vegetables Processed food Junk food Cereals Pulses

  Height  

  Cms

  Feet

  Inches

  BMI *

  Please Enter BMI

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