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 FEMALE QUESTIONNAIRE - PAGE 9 

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The following information will not be divulged in any form to any third party.

Items in red are required.


1.  Please tell us where and how to send your report

If you do not type your e-mail address correctly, we will not be able to send your report!

(1a) Your e-mail address:

(Please, check it carefully!)


(1b) How would you like to receive your report?
(1b) (If unsure, just skip here)
 
Delivery Method Description Password (optional)
We can add a password to your report
so that others can not read it

  Web Page (HTML)
        Recommended
View with any web browser.  See sample

Your report can easily be saved to your computer and viewed offline.
 
Not Available

  WinZip® Compressed
An HTML report (as above), compressed into a 'ZIP' file.  Please make sure that:
  • You have installed WinZip®
  • You can view this sample file
  • Your e-mail provider accepts "ZIP" attachments (most do not!)
Password - optional

(Please remember it!)

  Adobe® PDF (sample)
Please make sure that:
Password - optional

(Please remember it!)


2.  Contact Information

We require an alternative means of contacting you in case the above e-mail address is not working.

(2a) Telephone or Second E-mail:
(2a) (Alternative means of contact)

(2b) Address (optional):
Street
  ...continued
  City/Town
  State/District - required if in USA
  ZIP/Postal Code
  Country - required


4.  Further Medical Information:
 

(4a) Your height:
(4a) Enter feet or centimetres

 

(4b) Your weight:
(4b) Enter pounds, kilogrammes or stones

 

(4c) Your main concerns:
(4c) Please list up to 5 problems

(4d) Past hospitalizations/surgeries:
(4d) Please state the year if possible

(4e) Current drugs/medications:
(4e) Mention any drug allergies that you have

(4f) Other important information:
(4f) Enter anything not covered previously

(4g) Date of your last period:
(4g) If applicable, note as best you can
(4g) when your last period started


5.  Finally...
 

(5a) How did you find us?
(5a) ...or by whom were you referred?

(5b) Your occupation:
(5a) If retired, what was it?

(5c) Comments or suggestions:


 
 
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