Post-Intimacy Symptom Report Form
Use this form to report symptoms noticed after intimacy, describe severity and timing, and indicate the preferred follow-up. The form is designed to be clean, minimal, and easy to complete.
Report Details
Date and time symptoms were noticed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Approximate time since intimacy
*
Please Select
Within 1 hour
1–6 hours
6–12 hours
12–24 hours
1–2 days
More than 2 days
Not sure
Main symptom(s) experienced
*
Irritation
Pain
Itching
Burning
Swelling
Unusual discharge
Bleeding/spotting
Rash
Urinary discomfort
Other
Brief context or notes
Symptom Severity and Impact
Symptom Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How long have the symptoms lasted?
*
Please Select
Less than 1 hour
1-3 hours
3-6 hours
6-12 hours
12-24 hours
1-2 days
More than 2 days
Not sure
Since they started, the symptoms are:
*
Improving
Worsening
Unchanged
Not sure
Do the symptoms interfere with daily activities or comfort?
*
No
A little
A moderate amount
A lot
Not sure
Follow-Up Preference
Preferred next step
*
Self-monitor and observe symptoms
General advice only
Contact me about follow-up
Schedule a check-in appointment
Other
Preferred contact note or best time to reach you
Submit Report
Should be Empty: