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Vaginal Rejuvenation Questionnaire
Please fill out this form to help us understand your needs.
14
Questions
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1
Do you leak urine when you cough, sneeze or jump?
*
This field is required.
YES
NO
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2
Has it become difficult to control your urge to urinate?
*
This field is required.
YES
NO
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3
Have you given vaginal birth to one or more children?
*
This field is required.
YES
NO
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4
Are you dissatisfied with your external vaginal appearance?
*
This field is required.
YES
NO
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5
Has sexual intercourse become painful?
*
This field is required.
YES
NO
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6
Are you experiencing decreased libido?
*
This field is required.
YES
NO
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7
Are you experiencing itching and burning associated with dryness?
*
This field is required.
YES
NO
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8
Do you have difficulty achieving an orgasm?
*
This field is required.
YES
NO
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9
Do you have any history of pelvic surgery?
*
This field is required.
YES
NO
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10
Do you think you could benefit from Vaginal Tightening and Rejuvenation?
*
This field is required.
YES
NO
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11
Would you like to schedule an appt with Bluff City Health & Wellness?
*
This field is required.
YES
NO
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12
Name
*
This field is required.
First Name
Last Name
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13
Email Address
*
This field is required.
example@example.com
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14
Phone Number
*
This field is required.
Please enter a valid phone number.
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