Gynecological Diseases E-Consultation Form

  • Patient Information

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  • Common Questions

  • Do you have a dry mouth or a bitter taste in your mouth?*
  • Do you prefer to drink*
  • How are your bowel movements？*
  • What is the color of your urine first thing in the moring?*
  • How often do you get up to urinate during the night?*
  • How is the quality of your sleep?*
  • How is your energy?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do your hands and feet always feel cold ?*
  • Do you have migraines or headaches?*
  • What is your marriage status?*
  • How is your sexual drive?*
  • How is your mental stress or depression level ?*
  • How are your menstrual periods? (If you are looking for menopause treatment, please skip this question )
  • How many days are your cycles?*
  • How many days of period-related bleeding?*
  • How is the bleeding?*
  • How is the color of the blood?*
  • Are there any blood clots?*
  • Do you get any of these symptoms before, during, and/or after your period？*
  • How was the bleeding?*
  • How was the color of the blood?*
  • Were there any blood clots?*
  • Did you have any of these symptoms before, during, and/or after your last period？*
  • The main purpose of this consultation is for*
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  • Spouse Information

  • 2. How is male partner's sexual ability?*
  • 3. Does he have any medical conditions such as?*

  • Patient Assessment

  • During your period of ovulation, how much vaginal mucous do get on average?*
  • If you have vaginal mucous, what is the color?
  • If you have vaginal mucous, does it have a detectable odor?
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  • How often are your hot or cold flashes per day?*
  • Is there sweat accompanying your hot flashes?*
  • Is your mood irritability manageable?*
  • How is the quality of your sleep?*
  • How is your menstrual bleeding*
  • How was the bleeding?*
  • How was the color of the blood?*
  • Were there any blood clots?*
  • Did you have any of these symptoms before, during, and/or after your last period？*
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  • What is your complaint?*
  • Is it menstrual cycle related?*
  • Is it mood (irritation or stress) related?*
  • Is it accompanied by any of these symptoms? Select all that apply*
  • Are there any breast cysts or tumors checked by your MD?*
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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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