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Online Questionnaire

Elm Women's Clinic

Please complete the online questionnaire before your visit
to help us provide the best possible care.

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Please Select Your Questionnaire

For menstrual problems, abnormal bleeding, lower abdominal pain, vaginal discharge, menopausal symptoms, screening, etc.
If you suspect pregnancy, please start here.

Obstetrics
(Prenatal Care)

For those with confirmed pregnancy seeking prenatal care.
We provide prenatal care up to 32 weeks of gestation.

Termination
Consultation

For those not wishing to continue the pregnancy.
Please read the important information carefully before your visit.

📌 Before You Begin

This will take approximately 5-15 minutes
Your data is processed only in your browser
No data is sent until you submit
You can download a PDF, send by email, or print your questionnaire
If unsure which to choose, please start with Gynecology

⚠ For Urgent Symptoms

If you have severe pain, heavy bleeding, or loss of consciousness, please contact us or seek medical care directly rather than completing the questionnaire
Outside of our clinic hours, please contact a nearby emergency facility or call 119

Elm Women's Clinic

4-93 Chuo, Goshogawara, Aomori 037-0036, Japan
Phone: 0173-38-4188
Closed: Wed PM, Sat PM, Sun, Holidays
Clinic Official Website →