Green Discharge Symptom Intake Form
Please complete this form to help us assess 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
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
When did you first notice the green discharge?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe the green discharge (color, consistency, odor, amount):
*
Are you experiencing any of the following symptoms?
*
Pain or discomfort
Itching or irritation
Fever or chills
Burning during urination
Unusual odor
Other
Have you had any recent infections or been diagnosed with a sexually transmitted infection (STI)?
*
Yes
No
Not sure
Are you currently taking any medications? If yes, please list them.
Have you recently started a new sexual relationship or had unprotected sex?
Yes
No
Prefer not to say
For female patients: Are you currently menstruating or have you noticed any changes in your menstrual cycle?
Yes
No
Not applicable
Have you tried any self-treatment or home remedies for this symptom?
Yes
No
Please list any relevant medical conditions or allergies.
Is there anything else you would like to share about your symptoms?
Submit
Should be Empty: