Required so Niya can flag any safety concerns. Your information stays private.
Hormone & PCOS Screening
These symptoms are often dismissed or missed entirely by dermatologists, but they can be the actual driver of stubborn acne, dark patches, and hair changes. Your honest answers help Niya look beyond topical fixes.
Do you have irregular, painful, very heavy, or absent menstrual cycles?
Select...
No — regular cycles
Irregular (skipped months, unpredictable timing)
Absent for 3+ months (not pregnant / not menopause)
Very heavy or very painful
Post-menopausal
On hormonal birth control (no natural cycle)
Prefer not to say
Have you noticed unusual hair growth on your face, chin, chest, abdomen, or back?
Select...
No
Yes — mild (a few coarse hairs)
Yes — moderate (multiple areas, regular plucking/shaving/waxing)
Yes — significant (daily management)
Prefer not to say
Excess hair in male-pattern areas (hirsutism) is a classic PCOS marker.
Have you experienced unexpected weight gain or difficulty losing weight despite diet/exercise?
Select...
No
Yes — some unexplained weight gain
Yes — significant gain (20+ lbs in past 2 years without lifestyle change)
Yes — very difficult to lose weight even with effort
Prefer not to say
Have you ever been told you have, or been worked up for, any of the following?
PCOS / Polycystic Ovary Syndrome
Insulin resistance or pre-diabetes
Type 2 diabetes
Thyroid disorder (hypo or hyper)
Endometriosis
Adrenal disorder
Perimenopause / menopause symptoms
None of the above
Hold Ctrl (Windows) / Cmd (Mac) or tap multiple on mobile to select more than one.
Other hormone-related symptoms you've noticed (optional)
Pets & Household Exposures
Stubborn rashes, ringworm-looking patches, scalp irritation, and recurring breakouts on the face/arms/torso can come from animals in the home — both their dander and infections they pick up outside (ringworm, scabies, mange, fleas). Most dermatologists never ask. We do.
Do you have pets in your home?
Select...
No
Yes
What kind of pets? (select all that apply)
Dog
Cat
Rabbit
Bird
Reptile
Small mammal (hamster, guinea pig, ferret, etc.)
Livestock / farm animal
Other
Hold Ctrl/Cmd or tap multiple to select more than one.
Do your pets go outdoors (yard, walks, free-roam)?
Select...
No — indoor only
Yes — supervised (leashed walks, fenced yard)
Yes — free-roam outdoors
Mixed
Do your pets sleep in your bed or on your pillow?
Select...
No
Yes — in the bed regularly
Yes — on the pillow / face area
On the bed but not under covers
Occasionally
This matters more than people realize — direct contact transmits ringworm, scabies, and concentrates dander right at the face.
Have any of your pets had skin or coat issues recently (hair loss, scabs, scratching, redness, "hot spots," patches)?
Select...
No — their coat looks healthy
Yes — ongoing/unresolved
Yes — recently treated by a vet
Not sure / haven't checked closely
Pets can carry ringworm and mange long before they look obviously sick. If your skin issue won't resolve, we'll check this together.
Known pet allergies in the household?
Select...
No known allergies
Yes — mild (occasional sneezing, mild itching)
Yes — moderate (regular antihistamines)
Yes — severe (eczema flares, asthma, hives)
Suspected but not tested
