MonaLisa Touch® Questionairre

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MonaLisa Touch® Questionairre

MonaLisa Touch® Questionairre

1
Patient Information* This field is required.
First Name
Last Name
Date of BIrth
2
Treatment Stage
Prior to Treatment 1
Prior to Treatment 2
Prior to Treatment 3
Post Treatment 3
Prior to Interval Treatment
Prior to Annual Treatment
3
Pain Level* This field is required.Please indicate the level of pain you are experiencing for each category below
Vaginal Pain
Vaginal Burning
Vaginal Itching
Vaginal Dryness
Painful Intercourse
Painful Urination
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9Row 0, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6Row 1, Column 7Row 1, Column 8Row 1, Column 9Row 1, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3Row 2, Column 4Row 2, Column 5Row 2, Column 6Row 2, Column 7Row 2, Column 8Row 2, Column 9Row 2, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 3, Column 0Row 3, Column 1Row 3, Column 2Row 3, Column 3Row 3, Column 4Row 3, Column 5Row 3, Column 6Row 3, Column 7Row 3, Column 8Row 3, Column 9Row 3, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 4, Column 0Row 4, Column 1Row 4, Column 2Row 4, Column 3Row 4, Column 4Row 4, Column 5Row 4, Column 6Row 4, Column 7Row 4, Column 8Row 4, Column 9Row 4, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 5, Column 0Row 5, Column 1Row 5, Column 2Row 5, Column 3Row 5, Column 4Row 5, Column 5Row 5, Column 6Row 5, Column 7Row 5, Column 8Row 5, Column 9Row 5, Column 10
Vaginal Pain
Vaginal Burning
Vaginal Itching
Vaginal Dryness
Painful Intercourse
Painful Urination
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9Row 0, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6Row 1, Column 7Row 1, Column 8Row 1, Column 9Row 1, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3Row 2, Column 4Row 2, Column 5Row 2, Column 6Row 2, Column 7Row 2, Column 8Row 2, Column 9Row 2, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 3, Column 0Row 3, Column 1Row 3, Column 2Row 3, Column 3Row 3, Column 4Row 3, Column 5Row 3, Column 6Row 3, Column 7Row 3, Column 8Row 3, Column 9Row 3, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 4, Column 0Row 4, Column 1Row 4, Column 2Row 4, Column 3Row 4, Column 4Row 4, Column 5Row 4, Column 6Row 4, Column 7Row 4, Column 8Row 4, Column 9Row 4, Column 10
0 - Does Not Hurt
1 - Hurts a Little Bit
2 - Hurts a Little Bit
3 - Hurts
4 - Hurts
5 - Hurts More
6 - Hurts More
7 - Hurts a Lot
8 - Hurts a Lot
9 - Hurts the Most
10 - Hurts the Most
Row 5, Column 0Row 5, Column 1Row 5, Column 2Row 5, Column 3Row 5, Column 4Row 5, Column 5Row 5, Column 6Row 5, Column 7Row 5, Column 8Row 5, Column 9Row 5, Column 10
4
Stress IncontinenceRespond if treated for urinary symptoms
Remains the same
Slight improvement
Significant improvement
Resolved
5
Overactive BladderRespond if treated for urinary symptoms
Remains the same
Slight improvement
Significant improvement
Resolved
6
Comments
Huge
Large
Normal
Small
Ok
Ok
Should be Empty:

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