Women’s Health self-assessment- Questionnaires

1. What is your age group?

a) 20s and 30s
b) 40-50
c) 50 and above
2. Do you have diabetes?

Yes No

3. Do you have, or are you being treated for, high blood pressure?
o Yes, I have high blood pressure but I'm not being treated
o Yes, I am being treated for high blood pressure
o No
4. Have you had any of the following problems? (You can pick more than one)

 Severe headache
 Fatigue or confusion
 Vision problems
 Chest pain
 Difficulty breathing
 Irregular heartbeat
 Blood in the urine

5. Do you have any of the following symptoms in the breast?

 Brest cancer symptoms include:
 a pain in the armpits or breast that does not change with the monthly cycle
 pitting or redness of the skin of the breast, like the skin of an orange
 a rash around or on one of the nipples
 a discharge from a nipple, possibly containing blood
 a sunken or inverted nipple
 a change in the size or shape of the breast
 peeling, flaking, or scaling of the skin on the breast or nipple
6. Have you had any of the following? (You can pick more than one)
Frequent urination.
Excessive thirst.
Unexplained weight loss.
Extreme hunger.
Sudden vision changes.
Tingling or numbness in the hands or feet.
Feeling very tired much of the time.
Very dry skin

7. Have you been diagnosed with any of the following? (You can pick more than one
Kidney Awareness Day Page 1 of 2
 o Rheumatoid arthritis
o Liver disease
o HIV infection
o Multiple kidney stone
o Multiple urine infections, for example three or more in a six-month period

8. Do you have a family history of any these disease? (You can pick more than one)

o Parent or child who has a kidney disease that may be inherited

o Breast cancer
o Ovarian cancer
o Cervical cancer
o Hypertension
o Diabetes Meletus
o Cardiac disease
o Colorectal cancer.

9. Are you taking any of the following drugs?(You can pick more than one)
o Steroid
o Anti-hypertensive drugs
o Asthmatic drugs
o Diabetic drugs
o Neurologic drug.
o Any other drug
10. Do you have any kind of menstrual problems?

 Bleeding after menopause

 Bleeding after sex
 Bleeding between periods
 Heavy bleeding during your period (changing tampons every hour or two)
 Irregular cycles that vary by more than seven to nine days (such as having a 28-day cycle and
then a 38-day cycle)
 Menstrual cycles longer than 35 days or shorter than 21 days

11. Do you have any of the following problems

 smoking,
 excess alcohol consumption,
 low body weight
 menopausal status
 over weight
 bone pain

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