Healing Lives Together

+1 (888) 668-6339
info@medamorhealth.com
Find Us

Vaginal Rejuvenation Questionnaire

Home Vaginal Rejuvenation Questionnaire

Vaginal Rejuvenation

Step 1 of 9

11%

Name(Required)

First Name Family Name

Phone Number

Email(Required)

How old are you?

Less than 18

18 - 24

25 or more

How tall are you? (Ft-inches / cm)

How much do you weigh? (lb / Kg)

Are you currently sexually active?

Yes

No

Do you have sexual experience?

Yes

No

Have you ever had a vaginal delivery? How many times?

Yes, once

Yes, twice

Yes, three times

Yes, four or more times

No

Which of the following conditions apply to you? (Select as many as apply)

Vaginal laxity

Vaginal dryness

Discomfort during intercourse

Urinary incontinence

Which of the following apply to you? (Select as many as apply)

I'm pregnant

I'm breastfeeding

In the past 6 months, I’ve had an abortion

In the past year, I’ve had a vaginal delivery

I have a disability that limits my range of motion in my lower extremities

Currently I have an active vaginal infection or inflammation

I’ve had a pelvic surgery in the last 3 months

I have open wound(s) in my pelvic region

I have an active PID (Pelvic Inflammatory Disease) or STI (Sexually Transmitted Infection)

I have a cancer in the pelvic region

I have a bleeding disorder

I have an immune system disorder

I am taking immunosuppressive medications (including corticosteroids)

I am currently taking blood thinning medications

Please list the medications you’re taking including OTC, herbal/naturopathic and supplements?

Do you have any history of allergies?

Yes

No

If yes please specify

MedAmor is a sexual and physical wellness and aesthetic center in Ontario committed to enhancing well-being through a distinctive range of health and beauty services and the latest medical technologies.

Connect with Us

679 Davis Dr #206, Newmarket,
ON L3Y 5G8, Canada

+1 (888) 668-6339
+1 (888) NO TO ED 9
Fax: (647) 932-3436

info@medamorhealth.com

Quick links

Our Main Services