Bacterial Vaginosis Symptom Assessment Form
Please complete this form to help assess your symptoms and provide relevant health information for preliminary evaluation.
Full Name
*
First Name
Last Name
Age
*
Sex Assigned at Birth
*
Female
Male
Other
Are you currently pregnant?
*
Yes
No
Not sure
How long have you been experiencing your current symptoms?
*
Please Select
Less than 1 week
1-2 weeks
2-4 weeks
More than 1 month
Please indicate the presence and severity of the following symptoms:
*
Rows
Not Present
Mild
Moderate
Severe
Unusual vaginal discharge
1
2
3
4
Fishy vaginal odor
5
6
7
8
Vaginal itching or irritation
9
10
11
12
Burning sensation during urination
13
14
15
16
Vaginal redness or swelling
17
18
19
20
Have you experienced bacterial vaginosis before?
*
Yes
No
Not sure
Have you recently used any antibiotics?
*
Yes, within the past month
Yes, more than a month ago
No
Do you have any of the following risk factors? (Select all that apply)
Recent new sexual partner
Multiple sexual partners
Douching
Use of scented hygiene products
Other
Please provide any additional information about your symptoms or relevant medical history.
Submit Assessment
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