Questionnaire

NAME: -                                                                                                                       
AGE :-

RELIGION:-

SOCIO-ECONOMIC STATUS:-

Encircle the choice, do not leave any question unanswered

AWARENESS OF RISK FACTORS OF PCOS

1. Reduction in physical activities 1 ) Yes 2) No 3) don’t know

2. Change in intervals OR duration of menstrual cycle than usual. 1 ) Yes 2) No 3) don’t know

4. Continuous weight gain. 1 ) Yes 2) No 3) don’t know

5. High-carb and Fatty food Diet. 1 ) Yes 2) No 3) don’t know

6. Sedentary life-style 1 ) Yes 2) No 3) don’t know

7. Thyroid disorders 1 ) Yes 2) No 3) don’t know

8. Hormonal medications 1 ) Yes 2) No 3) don’t know

9. Family history. 1 ) Yes 2) No 3) don’t know

10. Where did you first learn about PCOS? [A] Newspapers and Radio [B] TV
[C]Health workers [D] Family, friends and colleagues

KNOWLEDGE ABOUT PCOS SIGN AND SYMPTOMS

11. Skin pigmentation -1 ) Yes 2) No 3) don’t know

12. Male pattern hair growth -1 ) Yes 2) No 3) don’t know

13. Baldness and thinning of hair -1 ) Yes 2) No 3) don’t know

14. Acne and oily skin changes -1 ) Yes 2) No 3) don’t know

15. Scanty bleeding -1 ) Yes 2) No 3) don’t know

16. Breast enlargement -1 ) Yes 2) No 3) don’t know