1.Name:

2.How do you feel about your current state of health?

Great-Very Healthy Symptoms Under Control

Fair- Some of the Symptoms Under Control

Poor-Everything is Going Crazy

Other (please specify)

3.What comes to mind when you think of PCOS (polycystic ovary Syndrome)?

4.What does a good day feel to you?

5.What is the most annoying symptom you have from PCOS?

6.What is your goal when dealing with PCOS?

7.Do you feel you have the necessary information and motivation when dealing with PCOS?

8.Would you prefer to have someone online or in person to help you with managing PCOS symptoms?

9.Is there anything that you currently do to relieve PCOS symptoms?