Beruflich Dokumente
Kultur Dokumente
1. Please check any of the symptoms below which have led you to seek medical attention here.
_____ Painful intercourse
_____ Burning after intercourse
_____ Vaginal discharge
_____ Vaginal burning
_____ Vaginal itching
_____ Vulvar burning
_____ Vulvar itching
_____ Clitoral pain
_____ Vulvar pain
_____ Urinary problems
_____ Other ________________________________________________________________
3. Did the symptoms start with any major life or gynecological events? (marriage, childbirth,
hysterectomy, surgery, bronchitis, new illness) _____________________________________
5. Have you had previous vulvar biopsies for this condition? __________________________
6. Have you been treated with medicines for this condition? (If yes, please give names and how
long you were treated)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. What medicine or treatment are you using now for this condition?
_______________________________________________________________________________
_______________________________________________________________________________
9. Do you have a history of any sexually transmitted diseases? If yes, which ones
_______________________________________________________________________________
10. Does your partner have symptoms of irritation, itching, burning or discharge ______________
11. Have you used any hormone therapy? If yes, how long ________________________________
12. Have you used oral contraceptives? If yes, how long __________________________________
13. Have your symptoms caused you to feel any of the following
_____ Fear of having to live with chronic pain
_____ Fear of possible cancer
_____ Loss of previously satisfying sex life
_____ Emotional, moody, frustrated and /or angry
_____ Relationship problems with your partner
_____ Fear of having a disease that you may give to others
_____ Isolation due to private nature of the problem.
_____ Antidepressant or anxiolytic use
_____ Ability to discuss the problem with family members or friends (if yes with whom)
Please name the specific products you use
1. Laundry detergent: _____________________________________________________________
2. Fabric softener:
_____ No
_____ Yes, Brand: _______________ How often: ______________________________________
3. Personal body soap: ____________________________________________________________
4. Douche:
_____ No
_____ Yes, What kind ____________ How often: ______________________________________
5. Feminine hygiene sprays, powders, perfumes, washes, or towelettes,
_____ No
_____ Yes, List _________________________________________________________________
6. Bath oils, bubble bath or bath salts:
_____ No
_____ Yes, List _________________________________________________________________
7. Toilet paper: Color _________ Brand: ___________ Scented? ___________
8. Tampons: Brand __________________ Deodorant? __________________________________
9. Pads: Brand ______________________ Deodorant? __________________________________
10. Type of underwear most commonly worn: Style: ____________________________________
_________ All cotton __________ Nylon with cotton liner
11. Frequency of pantyhose use:
_____ Never _____ Rarely _____ Occasional _____ Often
12. Lubricants or spermicides with intercourse:
_____ No _____ Yes, List _________________________________________________________
13. How many times a day do you wash the vulvar area? _________________________________
14. Water temperature with washing : ______ Hot _____ Warm _____ Cool
15. Do you use a wash cloth to wash the vulvar area? _____ No _____ Yes
_______________________________________________________________________________________
_______________________________________________________________________________________
__________________________________________________________________________________________________
FAMILY HISTORY: what have your family members suffered from medically?
Medical problem Which relative(s) had this?
Miscarriages
Eclampsia
Preterm labor
Diabetes
Hypertension
Stroke
Cancer
Breast cancer
Colon cancer
Ovarian cancer