Reproductive Health Survey
Acupuncture Buffalo uses a combination of diagnostic tools to help refine your treatment. This is only one of those tools. Please do not put pressure on yourself to answer things perfectly. This survey should take about five minutes to complete. Do not spend much time on any one question. If you are unsure, just pick "Maybe." We will discuss your results in person at your next visit.
Please enter the first two letters of your first and last name. Example: JaDo for Jane Doe. *
Your answer
Do you have lower back weakness, soreness, pain or knee pain? *
Do you have vaginal dryness? *
Do you have ringing in your ears or dizziness? *
Is your hair prematurely gray? *
Is your midcycle cervical mucus scanty or missing? *
Do you have night sweats? *
Are you prone to hot flashes? *
Would you describe yourself as afraid a lot? *
Do you have lower back pain premenstrually? *
Is your low back sore or weak? *
Are your feet cold, especially at night? *
Are you typically colder than those around you? *
Is your libido low? *
Are you often fearful? *
Do you wake up at night or early in the morning because you have to urinate? *
Do you urinate frequently, and is the urine diluted and/or profuse? *
Do you have early morning loose, urgent stools? *
Do you have profuse vaginal discharge? *
Does your menstrual blood tend to be pale in color? *
Do you feel cold cramps during your period that respond to a heating pad? *
Are you often fatigued? *
Do you have poor appetite? *
Is your energy lower after a meal? *
Do you feel bloated after eating? *
Do you crave sweets? *
Do you have loose stools, abdominal pain, or digestive problems? *
Are your hands or feet cold? *
Is your nose cold? *
Are you prone to feeling heavy or sluggish? *
Are you prone to feeling heaviness or grogginess in the head? *
Do you bruise easily? *
Do you think you have poor circulation? *
Do you have varicose veins? *
Are you lacking strength in your arms and legs? *
Are you lacking exercise? *
Are you prone to worry? *
Have you been diagnosed with low blood pressure? *
Do you sweat a lot without exerting yourself? *
Do you feel dizzy or lightheaded, or have visual changes when you stand up fast? *
Is your menstruation thin, watery, profuse, or pinkish in color? *
Are you more tired around ovulation or menstruation? *
Do you ever spot a few days or more before your period comes? *
Have you ever been diagnosed with uterine prolapse? *
Are your menstrual cramps accompanied by a bearing-down sensation in your uterus? *
Are you often sick or do you have allergies? *
Have you been diagnosed with hypothyroid or anemia? *
Do you have hemorrhoids or polyps? *
Are your menses scanty and/or late? *
Do you have dry, flaky skin? *
Are you prone to getting chapped lips? *
Are your fingernails or toenails brittle? *
Are you losing hair on your head (not in patches, but all over)? *
Is your hair brittle or dry? *
Do you have diminished nighttime vision? *
Do you get dizzy or lightheaded around your period? *
Is your menstrual flow ever brown or black in color? *
Do you feel midcycle pain around your ovaries? *
Do you have painful, unmovable breast lumps? *
Do you experience periodic numbness of your hands and feet (especially at night)? *
Do you have varicose or spider veins? *
Do you have red hemangiomas (cherry-red spots) on your skin? *
Do you have chronic hemorrhoids? *
Does your menstrual blood contain clots? *
Have you been diagnosed with endometriosis or uterine fibroids? *
Is your lower abdomen tender to palpation (resisting touch)? *
Can you feel any abnormal lumps in your lower abdomen? *
Do you have piercing or stabbing menstrual cramps? *
Have you ever been diagnosed with any vascular abnormality or blood clotting disorder? *
Are you prone to emotional depression? *
Are you prone to anger and /or rage? *
Do you become irritable premenstrually? *
Do you feel bloated or irritable around ovulation? *
Does it feel as though your ovulation lasts longer than it should? *
Are your breasts sensitive/sore at ovulation? *
Do you experience nipple pain or discharge from your nipples? *
Do you have a lot of premenstrual breast distention or pain? *
Have you been diagnosed with elevated prolactin levels? *
Do you become bloated premenstrually? *
Do you have difficulty falling asleep at night? *
Do you experience heartburn or wake up with a bitter taste in your mouth? *
Are your menses painful? *
Do you feel your menstrual cramps in the external genital area? *
Is the menstrual blood thick and dark, or purplish in color? *
Do you wake up early in the morning and have trouble getting back to sleep? *
Do you have heart palpitations, especially when anxious? *
Do you have nightmares? *
Do you seem low in spirit or lacking in vitality? *
Are you prone to agitation or extreme restlessness? *
Do you fidget? *
Do you sweat excessively, especially on your chest? *
Are your mouth and throat usually dry? *
Are you thirsty for cold drinks most of the time? *
Do you often feel warmer than those around you? *
Do you wake up sweating or have hot flashes? *
Do you break out with red acne (especially premenstrually)? *
Do you have a short (less than 25 days) menstrual cycle? *
Do you have vaginal irritation or rashes? *
Do you feel tired and sluggish after a meal? *
Do you have fibrocystic breasts? *
Do you have cystic or pustular acne? *
Do you have urgent, bright, or foul-smelling stools? *
Does your menstrual blood contain stringy tissue or mucus? *
Are you prone to yeast infections and vaginal itching? *
Do your joints ache, especially with movement? *
Are you overweight?
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