Women Health Survey
  • Name
  • Date of birth
  • Occupation
  • Do you have sleeping difficulties?
  • please specify
  • Is domestic violence present in your household?
  • please specify
  • Do you suffer from menopausal problems?
  • please specify:
  • Do you suffer from urinary incontinence?
  • please specify:
  • Do you have a family history of diabetes?
  • please specify:
  • Do you have a family history of breast cancer?
  • please specify:
  • Do you have a family history of ovarian cancer?
  • please specify
  • Have you gone for any sort of screening?
  • please specify:
  • Do you have a private physician?
  • please specify:
  • Do you have contacts to any of the following medical practitioners?
  • Have you ever been hospitalized?
  • please specify cause
  • Do you have healthcare benefits?
  • please specify what type
  • Do you have insurance?
  • please specify what type:

That's all, folks!

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