Women Health Survey

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0

Name
0

Date of birth
0

Occupation
0

Do you have difficulty sleeping?
Yes

No
0

Please elaborate

0 / 5000
0

Is domestic violence present in your household?
Yes

No
0

Please elaborate

0 / 5000
0

Do you suffer from menopausal problems?
Yes

No
0

Please elaborate

0 / 5000
0

Do you suffer from urinary incontinence?
Yes

No
0

Please elaborate

0 / 5000
0

Do you have a family history of diabetes?
Yes

No
0

Please elaborate

0 / 5000
0

Do you have a family history of breast cancer?
Yes

No
0

Please elaborate

0 / 5000
0

Do you have a family history of ovarian cancer?
Yes

No
0

Please elaborate

0 / 5000
0

Have you gone for any sort of screening?
Yes

No
0

Please elaborate

0 / 5000
0

Do you have a private physician?
Yes

No
0

Please elaborate

0 / 5000
0

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

OB/GYN

Family/general practice

Internist

Other (Please specify)
0

Have you ever been hospitalized?
Yes

No
0

Please specify why?

0 / 5000
0

Do you have healthcare benefits?
Yes

No
0

Who provides your healthcare benefits?
0

Please specify what type?
0

Do you have insurance?
Yes

No
0

What kind of insurance?
0

Who is your insurance provider?