Yeast Infection Treatment
Answer a few questions to confirm your eligibility for pharmacist-guided treatment.
Contact Information
Name
*
First Name
Last Name
What is your date of birth (MM-DD-YYYY)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
Symptom Screening
Are you 12 years of age or older?
*
Yes
No
Was your sex assigned at birth female?
*
Yes
No
Are you currently pregnant?
*
Yes
No
Have you ever been diagnosed with liver disease or kidney disease?
*
Yes
No
Have you had a vaginal yeast infection within the past 8 weeks?
*
Yes
No
Have you had 4 or more vaginal yeast infections in the past 12 months?
*
Yes
No
Do you have a history of uncontrolled diabetes or high blood sugar?
*
Yes
No
Do you have a condition that weakens your immune system or take medications that suppress your immune system (for example, active cancer, HIV, tuberculosis, poorly controlled diabetes, or an organ transplant)?
*
Yes
No
Are you currently using any of the following birth control devices: vaginal sponge, diaphragm, or IUD?
*
Yes
No
Symptom Screening
Are you experiencing any of the following?
Are you experiencing any of the following typical yeast infection symptoms?
*
Rows
Yes
No
Thick white, cottage cheese like vaginal discharge
Itching, burning, or irritation in the vaginal area
Are you experiencing any of the following?
*
Rows
Yes
No
Fever
Pelvic pain
Colored (yellow/green) or foul-smelling vaginal discharge
Pain with urination or increased urinary frequency
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Severe or persistent vomiting
Dehydration, dizziness, or very little to no urination in the last 24 hours
Sudden confusion, trouble speaking, or difficulty understanding speech
Sudden numbness or weakness in the face, arm, leg, or one side of the body
Trouble seeing in one or both eyes
Trouble walking, dizziness, loss of balance, or lack of coordination
Fever
*
Yes
No
Pelvic pain
*
Yes
No
Colored (yellow/green) or foul-smelling vaginal discharge
*
Yes
No
Pain with urination or increased urinary frequency
*
Yes
No
Difficulty breathing or shortness of breath
*
Yes
No
Pain or pressure in the chest or abdomen
*
Yes
No
Severe or persistent vomiting
*
Yes
No
Dehydration, dizziness, or very little to no urination in the last 24 hours
*
Yes
No
Sudden confusion, trouble speaking, or difficulty understanding speech
*
Yes
No
Sudden numbness or weakness in the face, arm, leg, or one side of the body
*
Yes
No
Sudden confusion, trouble speaking, or difficulty understanding speech
*
Yes
No
Trouble seeing in one or both eyes
*
Yes
No
Trouble walking, dizziness, loss of balance, or lack of coordination
*
Yes
No
Submit
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