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PCOD Screening

Demographic Details

Age *
Please Select Date of Birth

Age must be greater than 0 and less than 125 Years

Months must be less than 12

Days must be less than 31

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-

Days

Mnth

Yrs

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PCOD Screening

Do you have immediate family history of any of the adjacent diseases? *

Diabetes Hypertension Heart disease Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Others None

Do you have history of any of the adjacent diseases? *

PCOD/PCOS Diabetes Hypertension Heart disease/Stroke Lipid disorders (Cholesterol) Thyroid disorders Nutritional deficiencies (Vitamin B12/D/Calcium/Iron) Others None

Do you have irregular period cycles? *

Yes No

Do you have excessive facial hair growth? *

Yes No

Do you have frequent acne? *

Yes No

Have you experienced nipple discharge when neither pregnant nor breast feeding? *

Yes No

How many minutes in a week do you exercise? *

What does your diet predominantly contain? *

Fruits and Vegetables Processed food Junk food Cereals Pulses

Height

Cms

Feet

Inches

BMI *

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PCOD Screening

Clinic/Hospital/Doctor

Digital

Self

Existing Patient

Others

Corporate

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PCOD Screening

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Clinic/Hospital/Doctor

Digital

Self

Existing Patient

Others

Corporate

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