Women Health Survey
  • Name
  • Date of birth
  • Occupation
  • Do you have difficulty sleeping?

  • Please elaborate

  • Is domestic violence present in your household?

  • Please elaborate

  • Do you suffer from menopausal problems?

  • Please elaborate

  • Do you suffer from urinary incontinence?

  • Please elaborate

  • Do you have a family history of diabetes?

  • Please elaborate

  • Do you have a family history of breast cancer?

  • Please elaborate

  • Do you have a family history of ovarian cancer?

  • Please elaborate

  • Have you gone for any sort of screening?

  • Please elaborate

  • Do you have a private physician?

  • Please elaborate

  • Do you have connections to any of the following medical practitioners?

  • Have you ever been hospitalized?

  • Please specify why?

  • Do you have healthcare benefits?

  • Who provides your healthcare benefits?
  • Please specify what type?

  • Do you have insurance?

  • What kind of insurance?

  • Who is your insurance provider?

That's all, folks!

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