PCOS Nutrition Guide Intake Form
Help us understand your health background and dietary needs for a personalized PCOS nutrition plan.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Height (cm)
*
Weight (kg)
*
Have you been diagnosed with PCOS by a healthcare professional?
*
Yes
No
Not sure
What are your main symptoms related to PCOS? (Select all that apply)
*
Irregular periods
Acne
Excess hair growth
Weight gain
Hair loss
Mood changes
Other
How would you describe your current eating habits?
*
Balanced diet
High in carbohydrates
High in processed foods
Vegetarian/Vegan
Other
Do you have any specific dietary restrictions or preferences? (Select all that apply)
Vegetarian
Vegan
Gluten-free
Dairy-free
No red meat
No seafood
Other
How often do you engage in physical activity?
*
Please Select
Rarely/never
1-2 times per week
3-4 times per week
5 or more times per week
What are your main nutrition goals? (Select up to 2)
*
Weight management
Hormone balance
Improve energy levels
Reduce cravings
Improve skin health
Other
Is there anything else you would like to share about your health or nutrition needs?
Submit
Should be Empty: