Gynecological Diseases E-Consultation Form

Patient Information
Name*

First NameLast Name
Age*
Occupation*
Height (cm)*
Weight (lb)*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Common Questions
Do you have a dry mouth or a bitter taste in your mouth?*

Dry mouthBitter tasteNeither
Do you prefer to drink*

Cold waterRoom temperature waterWarm water
How are your bowel movements？*

Regular (1~2 times a day)Constipation (once per 2~3 days）Chronic diarrhea (loose stool 3~5 times a day)
What is the color of your urine first thing in the moring?*

Dark yellowLight regular yellowLight clear
How often do you get up to urinate during the night?*

1~2 times2~3 timesMore than 3 timesNone of these
How is the quality of your sleep?*

GoodWake up easilyDreaming
How is your energy?*

GoodMediumLowVery low
Do you have?*

Sore lower backSore kneesNone of these
Do you have?*

StressAnxietyDepressionNone of these
Do you have?*

Night sweatingHot flashesDay sweatingNone of these
Do you have?*

High blood pressureHigh blood cholesterolDiabetesNone of these
Do you have?*

CoughChest tightnessHeart palpitationsNone of these
Do you have?*

Stomach painIndigestionStomach bloatingCravingNone of these
Do your hands and feet always feel cold ?*

YesNo
Do you have migraines or headaches?*

YesNo
Do you have any allergies?*
How old were you when you had your first menstrual period?*
How long have you been on birth control pills?*
How many children have you given birth to?*
What is your marriage status?*

MarriedSingle
Have you had any gynecological tests? (ovary, fallopian tube, uterus, vagina, pelvic, breast, hormones) *
Is there any significant diagnosis of your gynecological conditions? (i.e., polycystic ovary syndrome, endometriosis, pelvic inflammation, auto-immune disease, hormone disorder, fibroids, cervical infection, STD, tumor/cancer, etc.)*
How is your sexual drive?*

NoneLowMediumHighVery high
How is your mental stress or depression level ?*

1-34-67-10No stress or depression
How are your menstrual periods? (If you are looking for menopause treatment, please skip this question )

RegularIrregular
How many days are your cycles?*

25-27 days28-30 days31-35 days
How many days of period-related bleeding?*

1-3 days4-7 days8-12 daysmore than 13 days
How is the bleeding?*

LightMediumHeavyVery heavy
How is the color of the blood?*

Dark-brownDarkNormal redVery red
Are there any blood clots?*

NoneFewMediumLots
Do you get any of these symptoms before, during, and/or after your period？*

HeadacheBreast tenderness and swellingRestlessnessEasy to angerMood swingStomach crampsSore lower backAbdominal heaviness and/or bloatingOthers (please list below)
Other
When was your last menstrual bleeding? *
How was the bleeding?*

LightMediumHeavyVery heavy
How was the color of the blood?*

Dark-brownDarkNormal redVery red
Were there any blood clots?*

NoneFewMediumLots
Did you have any of these symptoms before, during, and/or after your last period？*

HeadacheBreast tenderness and swellingRestlessnessEasy to angerMood swingStomach crampssore lower backAbdominal heaviness and/or bloatingOthers (please list below)
Other
The main purpose of this consultation is for*

Irregular menstruationInfertilityMenopauseBreast diseaseTumor/cancer
Spouse Information
Age*
Height (cm)*
Weight (lb)*
Occupation*
1. How is his general health condition? Is he healthy? Please give details, including any medical conditions.*
2. How is male partner's sexual ability?*

WeakNormalVery Strong
3. Does he have any medical conditions such as?*

ImpotenceSpermatorrhea (seminal emission)Premature ejaculationProstatitisTestitisNone of these
4. Please list ALL medications he is taking currently, including supplements and vitamins.*
5. Has he had a semen test, and if "Yes", what were the results?*
Patient Assessment
Have you had any miscarriages in the last few years? If you have ever had any miscarriages, when was your last one?*
How often do you have sex (intercourse) per week on average?*
How long have you been trying to get pregnant?*
During your period of ovulation, how much vaginal mucous do get on average?*

Very littleMediumHeavyVery heavyNone
If you have vaginal mucous, what is the color?

Transparent, colorlessWhiteBrown yellowish
If you have vaginal mucous, does it have a detectable odor?

YesNo
Have you had any IVF treatments? If "Yes", how many? When was the last one? When is your next one?*
How long have you been in menopause?*
When was your last menstrual period?*
How often are your hot or cold flashes per day?*

1-5 times6-10 times11-20 timesMore than 20 times
Is there sweat accompanying your hot flashes?*

YesNo
Is your mood irritability manageable?*

YesNo
How is the quality of your sleep?*

GoodLight sleeperFrequently wake-upFrequent nightmares
How is your menstrual bleeding*

RegularIrregularNone
When was your last menstrual bleeding? *
How was the bleeding?*

LittleMediumHeavyVery heavy
How was the color of the blood?*

Dark-brownDarkNormal redVery red
Were there any blood clots?*

NoneFewMediumLots
Did you have any of these symptoms before, during, and/or after your last period？*

HeadacheBreast tenderness and swellingRestlessnessEasy to angerMood swingStomach crampsSore lower backAbdominal heaviness and/or bloatingOthers (please list below)
Other
Is there anything else related? Details?*
What is your complaint?*

Breast tendernessBreast painBreast swelling
How long have you had this problem?*
Is it constant or intermittent?*
Is it menstrual cycle related?*

YesNo
Does it become worse a few days before, during or after your period?*
Is it mood (irritation or stress) related?*

YesNo
Is it accompanied by any of these symptoms? Select all that apply*

Headachesore lower backfatiguedepressionOthers (please list below)
Others*
Are there any breast cysts or tumors checked by your MD?*

YesNo
Is there anything else related? Please give details*
What kind of tumor/cancer is it?*
How long ago was it found?*
Are there any related symptoms or problems you have?*
Have you had any exam or diagnosis from an MD?*
Are there any other things related to your tumor/cancer? Please give details.*
Have you taken any herbal products or alternative medicine for your tumor/cancer? If "yes", please list below. *
Tongue Picture （Please upload your tongue pictures following the examples above）*

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E-consultation fee$60.00CAD

Total $0.00CAD

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Contact Us

AAHC-Ankang Acupuncture Healing Centre

Tel: 204-775-2266

Clinic website: https://acupuncturewinnipeg.ca

E-mail: ankangacupuncture@gmail.com

Add: 689 St Mary's Rd, Winnipeg, Manitoba, Canada
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Patient Information

Common Questions