Alberta Women's Cycles to Cessation Clinic

Pre-screening Form
Please not that due to provincial licensing regulations, we can only see patients who are residents of Alberta. Which province or territory in Canada are you a resident of?*

AlbertaOther

At this time, Cycles to Cessation is only funded to provide care to residents of Alberta. Please check local resources for available menopause treatment options.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

1. Will you physically be in Alberta at the time of your appointment?*

YesNo

Our clinic can only provide virtual care to patients who are in Alberta at the time of their appointment. Because you will not be in Alberta, we're unable to offer you care through this program.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

2. Participation in our program requires patients to have a computer, tablet, or phone with a working camera. Will you have access to a device with a working camera?*

YesNo

Our clinic visits are provided by secure video. Because you will not be using a device with a camera, we're unable to safely see you through our program.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

3. Do you currently have access to a doctor or a nurse practitioner that is publicly funded, meaning you do not pay privately for their services, who is knowledgeable in menopause care and is providing you with menopause care (e.g. prescriptions and menopause specific consultations)?*

YesNo

Cycles to Cessation is designed for patients who do not already have access to hormone therapy or menopause care. This helps us focus resources on patients who do not yet have care in place. Since you are already receiving treatment from another healthcare provider, we would suggest following up with your current healthcare provider. Thank you for your understanding.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

4. Do you understand that all appointments offered by our clinic are completed by secure video, and that in-person visits are not available?*

YesNo

Our clinic only provides care virtually by secure video. Patients interested in in-person appointments can seek care from their family doctor or nurse practitioner.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

5. Which age range do you fall under?*

39 and younger40 - 60 years61 and older

Our clinic specializes in caring for women in the perimenopause and menopause stages of life, which most commonly begin after age 40. We recognize that symptoms may start as early as the mid-30s and can persist beyond age 60. As funding allows, our goal is to expand services to better support women across this broader age range. At this time, our clinic is serving women between the ages of 40 and 60.

Thank you for completing the survey.

Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

7. Do you have high blood pressure that is not well controlled with medication? An example of high blood pressure would be greater than 140/90 mmHg.*

YesNo

Some menopause treatments, like hormone therapy, may not be safe if blood pressure is very high or not well controlled with medication. Because your blood pressure is not currently controlled, we are unable to provide you safe care through this virtual program.

Thank you for completing the survey. Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

8. Have you ever been diagnosed with a cancer that grows in response to estrogen, such as estrogen-receptor positive breast cancer or endometrial (uterine) cancer?*

YesNo

Certain cancers, like breast or uterine cancers that are sensitive to estrogen, can be made worse by hormone therapy. Because of this, our clinic cannot safely provide you with hormone therapy through this program. Care for people with these cancer histories requires close coordination with oncology specialists and in-person medical teams.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

9. Have you noticed any new breast changes, such as a lump, nipple discharge, or changes to the skin on your breast?*

YesNo

New breast changes need to be checked in person with tests like an exam or imaging. Because of this, our virtual clinic is not a safe option until you have been assessed in person.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

10. Do you have ongoing or worsening headaches or migraines with auras (Auras include symptoms like vision changes, weakness, numbness, trouble speaking, or fevers)?*

YesNo

Persistent or worsening headaches, especially with these added symptoms, may signal a more serious condition. Because this requires in-person tests and assessment, our virtual clinic is not a safe option until you have been evaluated by a healthcare provider.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

11. Do you have new or severe pelvic or lower belly pain?*

YesNo

New or severe pelvic pain may be caused by urgent conditions that need in-person tests, such as an exam, ultrasound, or other investigations. Because of this, our virtual clinic is not a safe option until you have been assessed in person.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

12. Have you had vaginal bleeding that doesn't fit your usual period pattern, and that you can't explain or hasn't been checked by a healthcare provider?*

YesNo

Unexpected or unexplained vaginal bleeding needs an in-person assessment before it can be safely managed. Because this symptom may be linked to conditions that require tests such as an ultrasound or biopsy, our clinic cannot provide you with virtual care until this has been evaluated.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

13. Have you ever had a blood clot in your leg or lungs (for example, a deep vein thrombosis or pulmonary embolism), or do you currently have one?*

YesNo

Because a history of blood clots can make hormone therapy unsafe, our clinic cannot provide this treatment virtually. Patients with past or current blood clots need an in-person assessment and care plan to make sure treatment is safe.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

14. Have you ever had a stroke?*

YesNo

Because a past stroke or mini-stroke can make perimenopause and menopause care more complex, virtual care is not the safest option. Patients with this history need an in-person assessment and a treatment plan coordinated with specialists to ensure care is safe and effective.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

15. Do you have active liver disease?*

YesNo

Because active liver disease can make perimenopause and menopause care more complex, virtual care is not the safest option. Patients with this history need an in-person assessment and a treatment plan coordinated with specialists to make sure care is safe and effective.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

16. Do you have very heavy vaginal bleeding (for example, soaking through one or more pads an hour or passing large blood clots)?*

YesNo

Very heavy bleeding may be caused by a variety of conditions such as fibroids, polyps, or other changes in the uterus. These need in-person tests and assessment before treatment can be safely started. Because of this, our virtual clinic is not the safest option for you.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

17. Have you had any vaginal bleeding after going 12 months or more without a period (not including pregnancy or when using birth control that may stop your period)?*

YesNo

Any bleeding that happens more than 12 months after your final period (not related to pregnancy or birth control) needs in-person tests, such as a physical exam, ultrasound and/or biopsy, to find the cause. Because of this, our virtual clinic is not a safe option.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

18. Are you currently pregnant, trying to become pregnant, or breastfeeding?*

YesNo

Our clinic cannot provide care during pregnancy, while trying to conceive, or while breastfeeding. These situations require in-person care and close follow-up with your family doctor, nurse practitioner, or obstetrician to make sure care is safe for you and your baby. Once this stage has passed, you are welcome to re-apply to our program.

Thank you for completing the survey.
Unfortunately, you do not meet the eligibility criteria for virtual care at this time.

We understand this may feel frustrating. Your experience helps highlight the need for better, publicly funded women's health services in Alberta. If you'd like to support this work, please visit our website and explore the Advocacy section to learn how we can push for improved access to women's health care together.

I confirm that the information I have provided in this form is accurate and complete to the best of my knowledge. I understand that providing incomplete or incorrect information may affect my safety and could lead to significant risks, especially if treatment including hormone therapy, is based on inaccurate details.
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Pre-screening Form