Gynaecology and Obstetrics (Consultation Form) Attention: Our website will not store any of your personal information. After completing the form, please click on the ‘submit’ button and send the PDF document via email, or take a photo and send it to your therapist.Email About your menstruation(period)Age of first Mestruation Are you on birth control? Yes No Normal menstruation cycle is around 28days(25-31days).Do you have? irregular menstruation early menstruation delayed menstruation I have my period every ____days or changing from ____days to ____days A normal menstrual period lasts for 3-7 days.(1)First day-scanty (2)Second day -heavy (3)Third day-less heavy (4)Fourth day-scanty.How many days does your menstrual period last? no period(more than 3months) missed period(1-3months) 1-2days 3days 4days 5days 6-7days 7-10days 11-15days spotting between cycles light bleeding between cycles heavy bleeding between cycles The normal menstrual flow is about 50-80ml.How much is your menstrual flow volume? normal(4-5pads/day) scanty-less than 20ml(less than 4pads/day) profuse-more than 100ml(more than 5pads/day) The ormal Menstrual colour is dark red.What color is your menstrual flow? Black Brown dark red bright red pink light red orange gray The normal texture(quility of flow) is without blood clots,neithrer thin nor sticky,not coagulated.I have small size of clots large size of clots small amount of clots large amount of clots no clots smelly sticky normal Texture of vaginal discharge watery sticky gooey thick pasty foamy Colour of vaginal discharge clear milky white or off white dark yellow brown green grey Smell of vaginal discharge fishy smell foul smell normal The amount of vaginal discharge profuse normal scanty symptoms in the vaginal area itchy cold hot swelling pain burning sensation PMS Relatednormald – during pre-menstruation and/or during menstruation1) Slight tenderness/swelling in breasts 2) Slight heaviness/distention feelings in the lower abdomen 3) Slight back ache 4) Mood swingsI have breast tender pain before period during period after period on the left side on the right side How many days do the symptoms mentioned above last?_____days I have lower abdomen bloating pain cold warm pressure feelings before period during period after period How many days do the symptoms mentioned above last?_____days I have lower back pain tight weak&tired feeling cold warm before period during period after period What is the duration of the above symptoms?____days I have PMS symptoms like pimples headache dizzyness hot flushes irritation anxiety grief insomnia hungry depression swollen legs/feet fatigue cold lower limbs Obstetrics HistoryAre you currently pregnant? Yes No How many weeks you are in a pregnancy? try to turn a breech baby Yes No nember of ectopic pregnancy Numbers of Pregnancy Numbers of Miscarriage Number of abortion Number of Children(excluding adopted or stepped children) Do you have any problems in pregnancy or delivery?if yes,please describe more details. When is your due date? Is fetus engaged? Yes No When did last pregnancy occur? Duration of contraception pills Other contraception Any medications? Practitioners onlyPulse,tongue,diagnosis,treatmentPulse: Tongue: Diagonosis: Treatment:HiddenSignatureName: Date：
