Help me doctor I have a problem in the genital area Survey

Too shy to ask the Dr. Fill in. Print and give to him rather than you explianing your symptoms

This questionnaire is for you to take to your doctor for them to make a better assessment about your condition. We do not ask for any personal information, this is between you and your doctor. If you wish to learn more about what we do please visit www.candgmedicare.com your medical specialist team.

1. What sex are you?

What sex are you? Male

Female

Transgender

2. Where is the problem area

Where is the problem area Inside the the vagina

Inside the penis

In the testicles

The pelvic floor

The clitoris

The labia minora (lips)

The labia majora (lips)

Perinium (area between opening of vagina and anus)

Pelvic floor muscles

3. I have pain if...

I have pain if... I urinate

I open my bowels

I try to have sex

I do pelvic floor exercises

I insert a tampon

I try to pull the foreskin back from my penis

I touch my genitals

4. The symptoms I have..

The symptoms I have.. Burning and/or stinging during sex Feel as if there is a lump in my vagina Pain on any sort of penatration White spots around the labia areas Bleeding (other than menstrual)	White discharge Extreme itching in the genital area Unpleasant smell from the genital area Blisters Swelling in the genital area
Other (please specify)

5. Have you had surgery within the past year?

Have you had surgery within the past year? Yes

Name of surgical procedure?

6. Within the last 10 years I have been diagnosed with

Within the last 10 years I have been diagnosed with Vaginismus
Dyspareunia (painful sex)
vulvovaginal candidiaisis (yeast vaginitis)
Cancer (which part of the body)
Vaginal atrophy (dry irritated vagina)
Lichen sclerosis
Vulvodynia (vestibulitis)
Interstitial Cystitis/Painful Bladder Syndrome
Fibroids
Pelvic Organ Prolapse
Urinary incontinence
Over active bladder
Erectile dyfunction
Prostatitis

7. Within the last 10 years I have been treated for

Within the last 10 years I have been treated for STD's

Yeast Vaginitis

Venereal disease

Syphilis

Gonnorhea

Bacterial vaginosis

Chlamydia

Hepatitis

HIV/AIDS

Herpes genetial

Trichomoniasis

Pelvic Inflammatory Disease (PID)

8. Have you used any medications, (oral or topical) for your condition? Write the names of the medications.

Have you used any medications, (oral or topical) for your condition? Write the names of the medications. Oral OTC medication
Oral medication prescribed by your doctor
Herbal supplements
Topical treatment creams
Topical treatment powder
Other

9. I have given birth

I have given birth Ceasarean section no problems Ceasarean section with problems Natural delivery no problems Natural delviery with problems I had an episiotomy	I had lacerations I had tearing I had stitches I had a pelvic organ prolapse
What problems did you have?

10. Pregnancy

Pregnancy How many live childbirths?
How many still-born?
How many miscarriages?
How many abortions?