Bacterial Vaginosis Symptom & Treatment Intake Questionnaire Form
Please complete the Bacterial Vaginosis Symptom & Treatment Intake Questionnaire Form to help us understand your recent symptoms and treatment history. Your responses will help us provide better support.
Full Name
First Name
Last Name
Age Group
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55+
Have you experienced any of the following symptoms recently?
*
Unusual vaginal discharge
Fishy odor
Itching or irritation
Burning sensation
No symptoms
Other
How long have you been experiencing these symptoms?
*
Please Select
Less than 1 week
1-2 weeks
2-4 weeks
More than 1 month
Have you previously been diagnosed with bacterial vaginosis?
*
Yes
No
Not sure
What treatments have you used in the past for bacterial vaginosis?
*
Prescription antibiotics (oral)
Prescription antibiotics (vaginal)
Over-the-counter remedies
Home remedies
No previous treatment
Other
Are you currently using any treatments for bacterial vaginosis?
*
Yes
No
Do you have any known allergies to medications or treatments?
*
Yes
No
If yes, please specify your allergies.
Additional comments or relevant information
Submit
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