Bacterial Vaginosis Visit
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  • Format: (000) 000-0000.
  • What was your gender at birth?*

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*
  • When did your symptoms start?*
  • Do you have any of the following symptoms? (Select ALL that apply)*
  • What color is your discharge?*
  • How would you describe the vaginal discharge?*
  • Does the discharge have a fishy smell?*
  • Are you experiencing any pelvic pain not associated with a period or sex? (The pelvic area is located between the belly button and the thighs)*
  • In the past 2 weeks, have you taken oral antibiotics?*
  • Do you currently use any of the following? (Select ALL that apply)*
  • In the last 60 days, have you had an IUD (intrauterine device) inserted?*
  • In the past 90 days, have you been sexually active?*
  • In the past 90 days, have you had new or multiple sexual partners?*
  • Are you experiencing any of the following during or after sex? (Select ALL that apply)*
  • In the past 90 days, has your partner(s) experienced any genital symptoms (e.g., vaginal/penile discharge, itching, sores)?*
  • When were you last tested for STIs (sexually transmitted infections)?*
  • Is there a possibility you currenlty have an STI?*
  • Have you tried any medications for this episode of symptoms?*
  • Which medication(s) have you tried for this episode of symptoms? (Select ALL that apply)*
  • Have you had any of the following in the past? (Select ALL that apply)*
  • How many times have you had bacterial vaginosis in the past year?*
  • Were you prescribed any of the following medications to treat the previous infection? (Select ALL that apply)*
  • Was the medication used effective?*
  • Do you have a medication preference for your bacterial vaginosis treatment?*
  • Do you have diabetes?*
  • Have you had any type of pelvic surgery or procedure in the past 6 weeks (e.g. endometrial biopsy, abortion, loop electrosurgical excision procedure, etc)?*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*
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