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Required format:

DV5R6bFVPzTEWaAKWMesddgibiP4Mp9jPr

PCOS Heart Disease Study

What is your current age in years?

What is your country of birth?

What is the country you currently live in?

What is your height in inches?

What is your weight in pounds?

What is your ZIP or Postal Code?

What is your race?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

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Please write what your race is in the box below.

Are you of Hispanic or Latino ethnicity?

Yes

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What is your highest educational degree?

Some high school

High school

Some college

College

Some professional

Professional

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What is your employment?

Full time

Part-time

Student

Unemployed - not looking for job

Unemployed - looking for job

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What is your level of income (in US dollars)?

None

Less than 34,999

35,000-74,999

75,000-99,999

100,000-199,999

More than 200,000

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What is your insurance status?

Private insurance

Public insurance (for example, Medicaid or Medicare)

Uninsured

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What is your marital status?

Single, never married

Married or domestic partnership

Divorced, separated, or widowed

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Have you been diagnosed with PCOS by a medical doctor?

* must provide value

Yes

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How many years ago was your PCOS diagnosis made?

* must provide value

Less than 1 year

1-5 years

6-10 years

11-15 years

16-20 years

More than 20 years

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Who primarily manages your PCOS?

* must provide value

If other, please specify:

* must provide value

Do you or have you experienced too frequent, infrequent, absent, or irregular periods?

* must provide value

Yes

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Do you or have you experienced increased hair growth, acne, hair loss, or high male hormones?

* must provide value

Yes

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Have you ever been told that you have polycystic appearing or enlarged ovaries on ultrasound?

* must provide value

Yes

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Do you or have you experienced excessive weight gain or difficulty managing weight?

* must provide value

Yes

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How did you find out about this survey?

* must provide value

If other, please specify:

* must provide value

Did a doctor or provider discuss any cardiovascular or heart complications specific to PCOS?

* must provide value

Yes

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Which of the following cardiovascular complications were discussed? Please select all that apply.

* must provide value

Hypertension or high blood pressure

Obesity

High cholesterol

High blood sugar

Sleep apnea

Fatty liver disease

Heart disease

How satisfied were you with regard to the information that you were given about cardiovascular disease risk?

* must provide value

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

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Have you received weight management counseling?

* must provide value

Yes

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What did the information regarding weight management include? Please select all that apply.

* must provide value

Nutrition recommendations

Exercise recommendations

Medications

Supplements

Other

If other, please describe:

* must provide value

How satisfied were you with regard to the information that you were given about weight management?

* must provide value

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

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What do you currently do for weight management?

* must provide value

Nutrition

Exercise

Use medications

Use supplements

Other

None

If other, please describe:

* must provide value

Do you have or have you ever been told that you have high blood pressure?

* must provide value

Yes

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Were you provided any information regarding blood pressure management?

* must provide value

Yes

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What did the information regarding blood pressure management include? Please select all that apply.

* must provide value

Blood pressure monitoring

Nutrition recommendations

Exercise recommendations

Stress management

Medications

Supplements

Other

If other, please describe:

* must provide value

How satisfied were you with regard to the information that you were given about weight management?

* must provide value

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

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How do you currently manage your high blood pressure?

* must provide value

Nutrition

Exercise

Medication

Supplements

Other

None

If other, please describe:

* must provide value

Do you have or have you ever been told that you have prediabetes or diabetes?

* must provide value

Yes

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Were you provided any information regarding prediabetes or diabetes?

* must provide value

Yes

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What did the information regarding prediabetes or diabetes management include? Please select all that apply.

* must provide value

Blood sugar monitoring

Nutrition recommendations

Exercise recommendations

Medications

Supplements

Other

If other, please specify:

* must provide value

How satisfied were you with regard to the information that you were given about prediabetes or diabetes management?

* must provide value

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

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How do you manage your prediabetes or diabetes?

* must provide value

Nutrition

Exercise

Medication

Supplements

Other

None

If other, please specify:

* must provide value

Do you have or have you ever been told that you have high cholesterol?

* must provide value

Yes

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Were you provided any information regarding cholesterol management?

* must provide value

Yes

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What did the information regarding cholesterol management include? Please select all that apply.

* must provide value

Nutrition recommendations

Exercise recommendations

Medications

Supplements

Other

If other, please specify:

* must provide value

How satisfied were you with regard to the information that you were given about cholesterol management?

* must provide value

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

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How do you currently manage your high cholesterol?

* must provide value

Nutrition

Exercise

Medication

Supplements

Other

None

If other, please specify:

* must provide value

From whom would you prefer to receive counseling about cardiovascular or heart disease risk in PCOS? Please select all that apply.

* must provide value

Internist/Primary Care Doctor

General OB/GYN Doctor

Reproductive Endocrinologist/Infertility Doctor

Endocrinology Doctor

Functional Medicine/Integrative Medicine Doctor

Naturopathic Doctor

Dietitian/Nutritionist

Exercise/Personal Trainer

A PCOS Patient Support Group

Other

None

If other, please specify:

* must provide value

How would you prefer to receive counseling about cardiovascular or heart disease risk in PCOS? Please select all that apply.

* must provide value

Individual talk or discussion

Group class or talk

Brochure or informational sheet

YouTube or online video

Podcast

Other

None

If other, please specify:

* must provide value

True

False

One of the main causes of heart attack and stroke is stress.

* must provide value

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Walking and gardening are considered types of exercise that can lower the risk of having a heart attack or stroke.

* must provide value

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Moderately intense activity of 2 ½ hours a week will reduce your chances of having a heart attack or stroke.

* must provide value

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People who have diabetes are at higher risk of having a heart attack or stroke.

* must provide value

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Managing your stress levels will help you to manage your blood pressure.

* must provide value

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Drinking high levels of alcohol can increase your cholesterol and triglyceride levels.

* must provide value

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HDL refers to 'good' cholesterol, and LDL refers to 'bad' cholesterol.

* must provide value

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A family history of heart disease is not a risk factor for high blood pressure.

* must provide value

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Strongly Disagree

Disagree

Agree

Strongly Agree

I feel I will suffer a heart attack or stroke sometime during my life.

* must provide value

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It is likely that I will suffer from a heart attack or stroke in the future.

* must provide value

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It is likely that I will have a heart attack or stroke some time during my life.

* must provide value

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There is a good chance I will experience a heart attack or stroke in the next 10 years.

* must provide value

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My chances of suffering from a heart attack or stroke in the next 10 years are great.

* must provide value

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It is likely I will have a heart attack or stroke because of my past and/or present behaviors.

* must provide value

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I am not worried that I might have a heart attack or stroke.

* must provide value

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I am concerned about the likelihood of having a heart attack or stroke in the near future.

* must provide value

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Strongly Disagree

Disagree

Agree

Strongly Agree

I am thinking about exercising at least 2 ½ hours a week.

* must provide value

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I intend or want to exercise at least 2 ½ hours a week.

* must provide value

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When I exercise for at least 2 ½ hours a week, I am doing something good for the health of my heart.

* must provide value

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I am confident that I can maintain a heathy weight by exercising at least 2 ½ hours a week within the next two months.

* must provide value

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I am not thinking about exercising for 2 ½ hours a week.

* must provide value

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When I eat at least five portions of fruit and vegetables a day I am doing something good for the health of my heart.

* must provide value

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Increasing my exercise to at least 2 ½ hours a week will decrease my chances of having a heart attack or stroke.

* must provide value

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I am unable to exercise for at least 2 ½ hours a week.

* must provide value

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Strongly Disagree

Disagree

Agree

Strongly Agree

I am confident that I can eat at least five portions of fruit and vegetables per day within the next two months.

* must provide value

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I am thinking about eating at least five portions of fruits and vegetables a day.

* must provide value

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I am not thinking about eating at least five portions of fruit and vegetables a day.

* must provide value

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I am unable to eat at least five portions of fruit and vegetables a day.

* must provide value

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What is your living situation today?

* must provide value

I have a steady place to live

I have a place to live today, but I am worried about losing it in the future

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

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Think about the place you live. Do you have problems with any of the following? (check all that apply)

* must provide value

Pests such as bugs, ants, or mice

Mold

Lead paint or pipes

Lack of heat

Oven or stove not working

Smoke detectors missing or not working

Water leaks

None of the above

Often true

Sometimes true

Never true

Within the past 12 months, you worried that your food would run out before you got money to buy more.

* must provide value

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Within the past 12 months, the food you bought just didn't last, and you didn't have money to get more.

* must provide value

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In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?

* must provide value

Yes

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In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home?

* must provide value

Yes

Already shut off

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Almost everyday

At least once a week

A few times a month

A few times a year

Less than once a year

Never

You are treated with less courtesy or respect than other people are.

* must provide value

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You receive poorer service than other people at restaurants or stores.

* must provide value

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People act as if they think you are not smart.

* must provide value

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People act as if they are afraid of you.

* must provide value

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You are threatened or harassed.

* must provide value

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If you responded "a few times a year" or more frequently to at least one of the above questions, what do you think is the main reason for these experiences? Please select all that apply.

* must provide value

Your ancestry or national origins

Your gender

Your race

Your age

Your religion

Your height

Your weight

Some other aspect of your physical appearance

Your sexual orientation

Your education or income level

A physical disability

Other

If other, please specify:

* must provide value

Are there any other questions you wished we asked you in this survey?

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