Post-Treatment Vaginal Discharge Symptom Check Form
Please complete this form to help us monitor your symptoms following your recent treatment. Your responses will assist your healthcare provider in delivering the best care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Date of Recent Treatment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Since your treatment, have you noticed any vaginal discharge?
*
Yes
No
Please select all symptoms you are currently experiencing (if any):
Unusual color of discharge
Unpleasant odor
Itching or irritation
Pain or discomfort
Increased amount of discharge
Other
How would you rate the severity of your current symptoms?
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Compared to before your treatment, your symptoms are:
*
Improved
Unchanged
Worsened
Are you experiencing any of the following additional symptoms? (Select all that apply)
Lower abdominal pain
Fever or chills
Pain during urination
None of the above
Are you currently menstruating?
Yes
No
Not applicable
Have you taken any new medications (including antibiotics) since your treatment?
Yes
No
Please provide any additional comments or concerns about your symptoms.
Submit Symptom Check
Should be Empty: