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Ayurveda
Ayurveda Initial Assessment
Body Type
Digestion Assessment
General Health Survey
For Women Only
Emotional Body Map
Addiction Questionnaire
Aromatherapy
Courses
Field Notes
First name
Last name
Which of the following describes your menstruation?
regular
absent
irregular
too frequent
infrequent
ceased due to menopause
How many days does your menstrual period last?
0-4
5-7
more than 7 days
spotty/irregular
Is your menstrual flow:
heavy
light
normal
Associated symptoms before or during menstruation
none
fluid retention
pain
acne
other
Do you have any discharge outside of your menstrual period?
Do you have any itching in the vaginal area?
Are you pregnant?
yes
no
I don't know
Number of children?
Number of pregnancies
Describe any complications with pregnancy:
Date
Day
Month
Month
Year
Submit
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