Yeast Infection Symptom Assessment
Please complete this form to help assess your current symptoms and risk factors for yeast infection. Your responses are confidential and assist in providing appropriate guidance.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What symptoms are you currently experiencing? (Select all that apply)
*
Itching or irritation
Thick, white vaginal discharge
Redness or swelling
Burning sensation
Pain during urination
Pain during intercourse
Odorless discharge
Other
How severe are your symptoms?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
When did your symptoms start?
*
-
Month
-
Day
Year
Date
Have you had a yeast infection before?
*
Yes, within the past year
Yes, more than a year ago
No
Not sure
Are you currently taking any medications (including antibiotics or antifungals)?
*
Yes, antibiotics
Yes, antifungals
Yes, other medications
No
Please indicate if you have any of the following risk factors:
Diabetes
Pregnancy
Recent antibiotic use
Weakened immune system
Use of hormonal contraceptives
Other
Please rate the impact of your symptoms on your daily life.
*
1
2
3
4
5
Please provide any additional information or concerns:
Submit Assessment
Should be Empty: