Post-Procedure Sexual Activity Guidance Form
Please provide the following information to receive personalized guidance on resuming sexual activity after your procedure.
Patient First and Last Name
*
First Name
Last Name
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Procedure
*
Name of Healthcare Provider or Clinic
When were you advised you may resume sexual activity?
*
Are there any restrictions or precautions you were advised to follow?
*
Which symptoms did your provider say require contacting the office?
*
What follow-up instructions were given regarding sexual activity?
*
Date of Next Scheduled Follow-Up (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Questions or concerns you would like to discuss with your provider
Submit
Should be Empty: