Ovarian Health Assessment Questionnaire Form
Assess ovarian-health related symptoms, cycle patterns, and follow-up preferences with this questionnaire. Use the exact title consistently throughout the form.
Respondent Overview
Full Name
*
First Name
Middle Name
Last Name
Age Range
*
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Primary Reason for Completing This Questionnaire
Menstrual and Cycle History
Date of Last Menstrual Period
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Typical Cycle Length (Days)
*
Cycle Regularity
*
Regular
Somewhat irregular
Very irregular
Symptoms and Experience Assessment
Symptom Severity/Frequency Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
Pelvic pain
1
2
3
4
5
Bloating
6
7
8
9
10
Fullness or pressure in the lower abdomen/pelvis
11
12
13
14
15
Unusual bleeding or spotting
16
17
18
19
20
Pain during movement or physical activity
21
22
23
24
25
Overall impact of these symptoms on daily activities
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Reproductive and Care Context
Known ovarian-related conditions or prior findings
Polycystic ovary syndrome (PCOS)
Ovarian cysts
Endometriosis
Ovarian torsion
Ovarian failure or insufficiency
Fertility-related evaluation findings
Previous pelvic imaging findings
Not sure
Current medications or hormonal treatments
Recent evaluation by a healthcare professional related to these symptoms
*
Yes
No
Not sure
Follow-up Preferences
Preferred follow-up option
*
Self-monitoring guidance
General informational follow-up
Appointment reminder
Other
Additional notes or concerns
Submit Questionnaire
Should be Empty: