VULVOVAGINAL DISORDERS CLINIC QUESTIONNAIRE (HIPAA compliant)

What sex were you assigned at birth?

Pronouns:ex: she/her, he/him, they/them

Date of birth:

Date

Address (street, city, state, zip):

Email:

example@example.com

Sexual orientation:

Straight or heterosexual

Lesbian, gay, or homosexual

Bisexual

Choose not to answer

Do you have any cultural or religious practices that may impact your care?

How much alcohol do you consume in a week?

How much tobacco do you consume in a week?

Do you take antibiotics prior to undergoing dental procedures?

Yes

Have you ever had a skin cancer?

Yes

I'm not sure

If you have had a skin cancer, please list the type, location on your body, and year of removal:

Who referred you to the Vulvovaginal Health Clinic:

Please list the referring physician's address (street, city, state, zip) and fax number:

What is your pharmacy's name and address (street, city, state, zip):

What is your pharmacy's phone number:

Please list all your current medications that you take by mouth, injection, or apply to your skin. Include any birth control or over the counter supplements.

Please list all of your allergies or medication intolerances and explain what your reaction is:

What is your vulvar or vaginal diagnosis, if known, and when did you first experience symptoms.

What are your vulvovaginal symptoms (i.e. itching, burning, rawness, pain, etc.)? Please give as much detail as possible.

If you are itchy, is it an itch that makes you want to rub and scratch?

Yes

Sometimes

If you rub or scratch, does it feel good at first?

Yes

Sometimes

Has this been a constant problem? (Meaning it is present all the time and you never have any relief)

Yes

Have you noticed anything in particular that worsens your condition?

Yes

If you answered yes, what worsens your condition?

Do your symptoms interfere with your sleep? (i.e. do they wake you up at night or prevent you from falling asleep?)

Yes

Sometimes

If you are sexually active, do you have pain with penetrative vaginal intercourse?

Yes

Sometimes

Do you have pain with other sexual activities? (I.e. manual stimulation, oral sex, anal sex, etc.)

Yes

Sometimes

If you are sexually active, have you ever experienced comfortable sexual activity at any point in time?

Yes

Please list all treatments (including prescription and non-prescription) that you have tried for this problem:

Have you had a vulvar biopsy? (A piece of skin removed from your genital area and sent to a laboratory)

Yes

Physician's name who performed the biopsy and the year it was performed:Please just put n/a if you have not had a biopsy.

Do you know what the biopsy showed?

What are you using right now on your genital skin for washing, lubrication, treatment or for any other reason? Please list any soaps, douches, powders, moisturizers, colognes, sprays, creams, ointments or other care regimen items

How often do you wash your genital area and what do you use to wash?

Have you been through menopause?If you have had a total hysterectomy (including removal of your ovaries) please select yes.

Yes

If yes, what year?If you had a hysterectomy that included removal of your ovaries, please specify the year here.

If no, when was the first day of your last menstrual period?

If you have periods, what do you use (check all that apply):

Tampons

Disposable pads

Menstrual cup

Disposable menstrual disc

Reusable menstruall disc

Cloth pads

Period underwear

Do you use any of the following incontinence products (check all that apply):

Disposable pantiliners

Cloth pantiliners

Disposable absorbent undergarments

Reusable absorbent undergarments

In the last 12 months, did you ever need feminine hygiene / sanitary products, but there wasn’t enough money to purchase them?

Yes

If yes, how often did this happen?

Almost every month

Only 1 or 2 months

Some months but not every month

I don’t remember

Have you ever been pregnant before?

Are you currently pregnant?

Yes

If you are currently pregnant, what is your estimated delivery date?

Have you breastfed a child in the past year?

Yes

If you answered yes, when was the last time you breastfed a child in the past year?

If you have been pregnant before, how many living children do you have?

Do you have a pacemaker or defibrillator?

Yes

Do you have any artificial joints or heart valves?

Yes

If yes, what year was your joint or heart valve surgery?

Have you ever been told that you have liver disease and/or hepatitis?

Yes

Have you ever been told that you have asthma?

Yes

Have you ever been diagnosed with a sexually transmitted infection?

Yes

I'm not sure

If you answered yes to the previous question, what type of infection and when was it diagnosed and treated?

Do you have problems with any of the following (check all that apply)

Energy level

Depression

Anxiety

Sleep

Headaches

Constipation

Diarrhea

Heartburn

Difficulty swallowing

Urinary frequency

Urinary burning

Urinary leakage

Bladder Urgency

Bladder pain

Mouth sores

Mouth dryness

Back Pain

Joint pain

Have you been diagnosed with any of these?:

Irritable bowel syndrome

Fibromyalgia

Temporomandibular joint disorder (TMJ)

Interstitial cystitis

Chronic fatigue syndrome

Pelvic pain

Endometriosis

Mast cell activation disorder

Ehlers Danlos

Do you have any other medical illnesses?

What do you think may be causing the problem?

Do you have any specific fears or worries concerning this problem?

Is there anything else I should know?