Vaginal Discharge and Cramping Symptom Intake
Please complete this form to help us understand your symptoms and provide appropriate care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
When did your symptoms start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe your vaginal discharge (color, consistency, odor)
*
How severe is your cramping?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Have you noticed any of the following symptoms?
Fever
Abnormal bleeding
Pain during urination
Pain during intercourse
Nausea/vomiting
Other
Are you currently pregnant or could you be pregnant?
*
Yes
No
Not sure
When was the first day of your last menstrual period?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any known allergies (medications, latex, etc.)?
Are you currently taking any medications? If yes, please list them.
Have you had any recent sexual activity?
Yes
No
Submit
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