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Vaginal Rejuvenation Questionnaire
Home
Vaginal Rejuvenation Questionnaire
Vaginal Rejuvenation
Step
1
of
9
11%
Name
(Required)
First Name
Family Name
Phone Number
(Required)
(By entering your phone number, you consent to be contacted through call and/or text on the phone number you enter.)
Email
(Required)
(By entering your email address, you consent to be contacted via email at the email address you provide.)
I opt to receive promotional information and clinic announcements on this number
I opt to receive promotional information and clinic announcements on this email
How old are you?
Less than 18
18 - 24
25 or more
How tall are you? (Feet/Inch/cm)
How much do you weigh? (lbs / Kg)
Feet/Inch
cm
lbs
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?
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?
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?
Add
Remove
Do you have any history of allergies?
Yes
No
Hidden
If yes please specify
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