Clear Data
Elizabeth Lee Vliet, M.D., P.C. HER Place®
Preventive and Climacteric Medicine
SELF TEST: DO YOU HAVE PCOS?
Poly-Cystic Ovary Syndrome (PCOS) is characterized by multiple small
ovarian cysts, obesity, hypertension, diabetes, insulin resistance, and
hirsutism (elevated levels of male hormones). The ovarian cysts may not
produce any definite symptoms, and may come and go, so they may not
show on ultrasound at the time the test is done. It may, therefore, be
difficult to prove the presence of this disorder. In view of the combined
cluster of problems you are experiencing (weight gain, glucose intolerance
and almost certain insulin resistance, hormonal imbalances, high blood
pressure), it may be reasonable to make treatment recommendations
based on what would be appropriate for PCOS.
YES
NO 1. I crave carbohydrates and sugar.
YES
NO 2. I have had continuous weight gain.
YES
NO 3. I have always had difficulty with losing weight.
YES
NO 4. My waistline is greater than 35 inches.
YES
NO 5. I have or had problems in the past with acne.
YES
NO 6. My periods last longer than 35 days.
YES
NO 7. My periods are unpredictable.
YES
NO 8. My periods last longer than a week.
YES
NO 9. My periods are very heavy or prolonged.
YES
NO 10. I have with excess facial hair.
YES
NO 11. I have symptoms of hypoglycemia.
YES
NO 12. I have a family history of diabetes.
YES
NO 13. I have a family history of cardiovascular disease.
YES
NO 14. I have a history of gestational diabetes.
YES
NO 15. I feel extremely hungry, irritable, sleepy, or fatigued
after eating sweets.
YES
NO 16. I have noticed skin color or pigmentation changes.
YES
NO 17. I have a history of high blood pressure.
YES
NO 18. I have had difficulties getting pregnant.
YES
NO 19. I have PMS symptoms.
YES
NO 20. I have unusual amount of hair on my breasts.
YES
NO 21. I have hair growth on my upper thighs.
YES
NO 22. I have pubic hair that grows up my abdomen and
around the navel.
YES
NO 23. My acne is worse at different times of my cycle.
0 = Number of Yes Checks or 0.00%
©ELIZABETH LEE VLIET, M.D. 1995-2006 P.O. BOX 64507
PCOS QUESTIONNAIRE TUCSON, AZ 85728
(520) 797-9131