Please complete the PCOS Diva Symptom Assessment before you begin the 21-Day Plan and then again when you finish. This exercise will help you to identify your symptoms and measure how much they improve in only 21 days. You will feel so much better after completing the plan that you may forget how lousy you felt at the beginning. Comparing the before and after scores will help you to quantify the change.
On a scale from 1 to 5, rate your current PCOS symptoms.
1 = I do not experience this symptom.
2 = The symptom is a minor problem. I notice the symptom, but it is not a big concern.
3 = The symptom is a moderate problem for me. It impacts my life, but I can manage it.
4 = The symptom is a serious problem. I continually struggle with it.
5 = The symptom is severe. I can barely function.
| Date: | |||||
| SYMPTOM | |||||
| Acne | 1 | 2 | 3 | 4 | 5 |
| Bloating | 1 | 2 | 3 | 4 | 5 |
| Irritability | 1 | 2 | 3 | 4 | 5 |
| Fatigue | 1 | 2 | 3 | 4 | 5 |
| Moodiness | 1 | 2 | 3 | 4 | 5 |
| Stress | 1 | 2 | 3 | 4 | 5 |
| Brain Fog | 1 | 2 | 3 | 4 | 5 |
| Low Libido | 1 | 2 | 3 | 4 | 5 |
| Weight Gain | 1 | 2 | 3 | 4 | 5 |
| Irregular Cycle | 1 | 2 | 3 | 4 | 5 |
| Blood-Sugar Swings | 1 | 2 | 3 | 4 | 5 |
| Other ______________________ | 1 | 2 | 3 | 4 | 5 |
| Total of Each Column | |||||
| Total Score | |||||