AIAVS
ALINSOD INSTITUTE
for AESTHETIC VULVOVAGINAL SURGERY
INITIAL HISTORY AND PHYSICAL
Date
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/
Month
/
Day
Year
Date
Patient Name
*
Age
*
Date of Birth
*
/
Month
/
Day
Year
Date
Last Menses (1st Day)
*
Pregnancies
*
Births
*
Vaginal
*
Cesarean
*
Miscarriages
*
Abortions
*
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (Home)
*
Phone (Work)
*
Phone (Cell)
*
Email
*
example@example.com
Allergies
*
None
Yes
Referring Physician
*
How did you hear about us?
*
CHIEF COMPLAINT (Why you want to see the doctor today?)
*
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AESTHETIC VULVOVAGINAL SURGERY QUESTIONAIRE
AESTHETIC VULVOVAGINAL SURGERY QUESTIONAIRE
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I want aesthetic vaginal surgery
My labia are larger/looser than what I want
I do not like the way my labia looks
My labia rub, tug, and pull on my clothing
I am unable to wear the type of clothing I want
I have had unflattering comments about my geital region
I have had difficult births
My vagina feels too loose inside
I have decreased sensations
I feel pelvic heaviness and pressure
Sex is uncomfortable/unpleasant
I rely on my appearance at work
I am interested in G-Spot treatments
INTERESTED IN NON-SURGICAL TREATMENTS
To tighten the labia majora
To tighten the vagina
To treat a leaky bladder
To reduce urinary urgency and frequency
To improve vulvar and vaginal moisture
To improve sensitivity of tissures
To improve or achieve orgasms
Reduce painful intercourse
INTERESTED IN AESTHETIC LASERS/IPL/RADIOFREQUENCY TREATMENTS
I want Vulvar Lightening
I want to remove brown spots/sun damage
I want to remove red blood vessels
I want FotoFacial/Fraxel
I want Hair or/and Vein reduction
I want Skin Tightening
I want Botox/Skin Fillers
I want Stretch Marks/Scar Reduction
I want Collagen/Vitamin C Facials
I want info on Skin Care Products
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PAST MEDICAL HISTORY/REVIEW OF SYSTEMS (other current health problems):
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Are you physically active?
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No
Yes. What type of exercise?
Do you now have or have you ever had:
Neurologic (seizures, headaches, weakness, paralysis) problems?
*
Yes
No
Psychiatric problems? Depression? Mania? Bipolar?
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Yes
No
Head/Ear/Eyes/Nose/Throat Problems?
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Yes
No
Thyroid problemsor glandular problems?
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Yes
No
Cardiac (heart) problems? Palpitations? Chest Pain? Irregular Beat?
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Yes
No
Lung Problems? Asthma? Short of Breath?
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Yes
No
Breast Problem? Mass? Lumpiness? Discharge? Pain?
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Yes
No
Gastrointestinal (stomach) problems?
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Yes
No
Kidney or bladder disease? Stones? Infections? Blood in urine?
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Yes
No
Liver problems such as hepatitis?
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Yes
No
Hematologic problems such as bleeding or anemia?
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Yes
No
Diabetes (insulin dependent/oral medication) or low sugar?
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Yes
No
Musculoskeletal (bones, joints, muscles) problems?
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Yes
No
Circulation problems (varicose veins, thrombosis, blood clots)?
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Yes
No
Cancer or Pre Cancerous Conditions
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Yes
No
High Blood Pressure or Low Blood Pressure/Fainting Spells
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Yes
No
Hernias in the abdomen
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Yes
No
Problems with anesthesia, nausea, anxiety reaction?
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Yes
No
STD (HIV, Gonorrhea, Chlamydia, Hepatitis, Syphilis, Warts)
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Yes
No
Other Problems
*
PAST SURGERIES OR HOSPITALIZATIONS
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NONE
Please list with date:
FAMILY HISTORY (Write which has occurred in any blood relative and write relationship to you):
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None significant
Yes, type and in whom
SOCIAL HISTORY:
Marital Status:
*
S
M
W
D
Education:
*
Occupation
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Not Working
Working (Where? What Occupation?)
Tobacco use:
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No
Yes
Alcohol use:
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No
Yes
Caffeine Use:
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No
Yes
Other Drugs:
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No
Yes
Abuse
*
No
Yes, describe
Medications:
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NONE
SEE ATTACHED LIST, please list all medications and dosages
Submit
Should be Empty: