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Perimenopause
PCOS
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Height
Weight
Last Menstrual Period
Number of Children (if applicable)
Symptoms of Hormonal Imbalance
Dry skin
Muscle pain
Fatigue
Weight gain
Weight loss
Mood swings
Hair loss
Constipation
Loss of appetite
Indigestion after food
Feeling cold
Hot flashes
Dry vagina
Burning during urination
Are you currently experiencing irregular periods?
Yes
No
Have you experienced night sweats?
Yes
No
Do you have sleep disturbances or insomnia?
Yes
No
Do you experience vaginal dryness or discomfort during intercourse?
Yes
No
Have you noticed a reduction in libido?
Yes
No
Have you had mood changes like irritability or depression?
Yes
No
Do you experience joint or muscle aches that are new?
Yes
No
Have you experienced memory problems or brain fog?
Yes
No
Any previous surgery
Any medical problem for which you are taking medicines
Any important family history like diabetes or hypertension
Have you been diagnosed with PCOS before?
Yes
No
Age of Diagnosis (if applicable)
Last Menstrual Period
Do you experience irregular periods?
Yes
No
Have you experienced any of the following symptoms of PCOS? (select all that apply)
Irregular or missed periods
Heavy menstrual bleeding
Excess facial or body hair (hirsutism)
Acne
Thinning hair or hair loss
Weight gain or difficulty losing weight
Dark patches of skin (e.g., on neck, armpits)
Skin tags
Do you experience pelvic pain?
Yes
No
How often do you exercise?
Rarely or never
1–2 times per week
3–5 times per week
Daily
What type of diet do you follow?
Standard diet
Low-carb or keto diet
Vegetarian or vegan
Other
Do you experience cravings for sugar or carbohydrates?
Yes
No
Do you sleep well at night?
Yes
No
Do you have a family history of any of the following conditions? (select all that apply)
Diabetes
Hypertension
Obesity
PCOS
Thyroid issues
Are you currently taking any medications for PCOS or hormonal imbalances?
Have you been diagnosed with any of the following? (select all that apply)
Insulin resistance
Type 2 diabetes
Thyroid disorder
High cholesterol
Have you undergone any of the following treatments? (select all that apply)
Oral contraceptives
Metformin
Fertility treatments
Others
What symptoms or concerns related to PCOS are you currently experiencing?
What are your primary goals in managing PCOS?
How would you rate your current cognitive performance?
Excellent
Good
Average
Poor
Do you experience any of the following cognitive symptoms? (select all that apply)
Memory lapses or forgetfulness
Difficulty concentrating or staying focused
Brain fog
Slow thinking or processing speed
Difficulty with decision-making
Difficulty multitasking
Frequent mental fatigue
How many hours of sleep do you get on average per night?
Less than 4 hours
4–6 hours
6–8 hours
More than 8 hours
Do you feel rested upon waking?
Yes
No
How often do you exercise?
Rarely or never
1–2 times per week
3–5 times per week
Daily
What type of diet do you follow? (select all that apply)
Standard diet
Low-carb or keto diet
Vegetarian or vegan
Mediterranean diet
Other
Do you consume any of the following regularly? (select all that apply)
Processed or junk food
Sugary snacks or drinks
Alcohol
Caffeine (coffee, tea, energy drinks)
Do you have a history of any of the following conditions? (select all that apply)
Traumatic brain injury
Stroke
Depression
Anxiety
ADHD or ADD
Alzheimer's disease or dementia
Other neurological conditions
Do you have a family history of neurological or cognitive conditions? (select all that apply)
Alzheimer's disease or dementia
Parkinson's disease
Stroke
ADHD or ADD
Other
Are you currently taking any medications for brain or neurological health?
How often do you engage in activities that challenge your brain (e.g., puzzles, learning new skills)?
Daily
A few times a week
Rarely
Never
How often do you feel stressed?
Rarely
Sometimes
Frequently
Constantly
Do you practice any stress-management techniques? (select all that apply)
Meditation or mindfulness
Yoga
Deep breathing exercises
Journaling
Physical exercise
Other
What are your primary concerns related to brain health or cognitive performance?
What goals do you have for improving your brain health?
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