SHC's comprehensive wellness initiative seeks to provide patients with a variety of choices during every stage of their menstrual cycles. Personalized feedback from this survey ensures that you are well informed and able to make the best decisions for what your body needs to stay healthy.
Tell us about yourself! What is your name?
What email can we send your personalized wellness report and feedback to?
Overall, how would you rate your health?
Do you suffer from any of the following?
High Blood Pressure
GI Reflux Diease
Other GI diease
Kidney Infections / Stones
Do you have any family history for any of the illnesses listed above? Please explain
What aspect of your health are you looking to learn more about? (Check all that apply)
Fertility (both male and female)
Menstruation symptoms and side effects
Irregular, abnormal, or non existent periods
Sexual health (gynecological concerns, sexual arousal, sexually transmitted infections, etc)
Nutrition and healthy weight management
Stress, anxiety, and tension
Pain, both chronic and acute
Depression and irregular moods
Post birth support
Low energy, fatigue
Digestion concerns (Indigestion, acid re-flux, constipation, etc)
Insomnia or trouble sleeping
Addictions and compulsive behaviors
Breast health and self examinations
Do you have children or are planning to have children?
Do you experience any of the following in your ears, nose or throat? Check all that apply
Ringing in the ears
Sore throat or mouth sores
Do you experience any of the following cardiovascular system issues? Check all that apply.
Swelling of legs
Do you experience any of the following respiratory system issues? Check all that apply.
Spitting up blood
Shortness of breath
Do you experience any of the following gastrointestinal problems? Check all that apply.
Liver problems / Hepatitis
Do you have any of the following skin and health concerns? Check all that apply.
Do you experience any of the following emotional conditions? Check all that apply.
Do you experience any of the following not previously listed? Check all that apply.
Cold / heat intolerance
Cuts do not stop bleeding
Enlarged Lymph nodes
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