| QUESTION |
CRITERIA TO ATTAIN SCORE VALUE |
SCORE VALUE |
|
| Please answer this question, NOT INCLUDING any time spent pregnant, receiving birth control pills or injections, after menopause, or after having both ovaries or the uterus surgically removed: |
Patient indicates any one of- 35–60 d
- more than 60 d
- totally variable
|
1 |
Between the ages of 16 and 40, about how long was your average menstrual cycle (time from first day of one period to the first day of the next period)? (select ONE only)- <25 d
- 25–34 d
- 35–60 d
- More than 60 d
- Totally variable
|
|
|
During your menstruating years (not including during pregnancy), did you have a tendency to grow dark, coarse hair on your (circle ALL that apply)- upper lip?
- chin?
- breasts?
- chest between the breasts?
- back?
- belly?
- upper arms?
- upper thighs?
|
Patient indicates 3 or more sites |
1 |
| Were you ever obese or overweight between the ages of16 and 40? (circle ONE) |
|
|
| • Yes |
Patient indicates Yes |
1 |
| • No |
|
|
| Between the ages of 16 and 40, have you ever noticed a milky discharge from your nipples (not including during pregnancy or recent childbirth)? (circle ONE) |
|
1 |
| • Yes |
Patient indicates Yes |
–1 |
| • No |
Patient indicates No |
0 |
| TOTAL |
|
If  2, consistent with diagnosis of PCOS |
|
|
If <2, not consistent with diagnosis of PCOS |
