Vaginal Rejuvenation Intake
Full Name
*
First Name
Last Name
Birth Date
*
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Year
Age
Phone Number
*
-
Area Code
Phone Number
E-mail
*
ex: example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
How did you hear about vaginal rejuvenation?
*
Referral
Social Media
Tula Wellness
Newpaper/Magazine
Other
What is your number one reason for this appointment?
*
Stress Incontinence
Vaginal Dryness/ Vaginal Laxity
Sexual Dysfunction
Other
How long has this been a concern for you?
*
Have you had to adjust your lifestyle because of symptoms?
*
No
Yes
If yes, please explain.
When was your last menstrual period?
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Month
-
Day
Year
Date Picker Icon
Have you had pelvic surgery?
*
No
Yes
If yes, please list.
Please list all other surgeries, if any.
Have you given birth vaginally?
*
No
Yes
If yes, how many vaginal births and their birth weight?
Did you experience extensive tears with childbirth or require and epiostomy?
Do you have a history of abnormal pap smear(s)?
*
No
Yes
Date of last pap smear?
*
-
Month
-
Day
Year
Date Picker Icon
Please list all medications you are currently taking. If none, please type none in the box
*
Please list all medical issues, if any. If none, please type none in the box.
*
Stress Incontinence:
Do you wear a bladder pad or panty liner?
*
No
Yes
Do you experience incontinence when lifting?
*
No
Yes
Do you experience incontinence with exercise? Ex; Jumping Jacks, Zumba, Running
*
No
Yes
What are your most concerning symptoms regarding your incontinence?
Vaginal Dryness/Laxity:
How often do you have intercourse?
*
Do you experience pain with intercourse? If yes, please explain below.
*
No
Yes
Explain experience with pain during intercourse, if any.
Have you used medications or products for vaginal dryness? If yes, please list below.
*
No
Yes
List medications or products used for vaginal dryness, if any.
Are you now, or have you ever used hormone replacement therapy? If yes, please list below.
*
No
Yes
List hormone replacement therapy, if any.
Sexual Dysfunction:
Have you experienced difficulty with arousal?
*
No
Yes
Have you experienced difficulty achieving orgasm?
*
No
Yes
Have you experienced prolonged time to achieve orgasm?
*
No
Yes
Are you able to achieve orgasm through clitoral stimulation?
*
No
Yes
Are you able to achieve climax through vaginal intercourse?
*
No
Yes
Do you have any concerns about the appearance of your vulva?
*
No
Yes
Is your partner aware that you are considering vaginal rejuvenation?
*
No
Yes
If you are not having intercourse, are you having intimate time with your partner?
*
No
Yes
Are you interested in discussing hormone replacement?
*
No
Yes
Are you interested in learning more about hormone replacement therapy for symptoms of Perimenopause or Menopause? i.e.: weight gain, hot flashes, mood swings, vaginal dryness, decreased libido, abnormal menstruation
*
No
Yes
Have you ever had Pelvic Floor Therapy?
No
Yes
Is there a specific vaginal rejuvenation treatment you are interested in? If yes, please specify which treatment below.
No
Yes
Other
Do you have commercial insurance? If yes, please specify below.
*
No
Yes
If you selected yes to the question above, please specify what insurance you have in the box. If you do not have Commercial Insurance, please type N/A in the box.
*
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