Vulvar Vaginal Disorders Clinic Patient Questionnaire

Name: ___________________ Birth date: ___/___/___ Date form filled: ___/___/___

Name of Referring Physician: _____________________________

Name of Primary Care Physician: _____________________________

Please answer the following questions as best you can.

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 ________________________________________________________________

2. How long have you had these symptoms ________________________________________

3. Did the symptoms start with any major life or gynecological events? (marriage, childbirth,
hysterectomy, surgery, bronchitis, new illness) _____________________________________

4. Has you condition been given a name? _________________________________________

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?
_______________________________________________________________________________
_______________________________________________________________________________

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8. Do your symptoms prevent you from doing any activities such as working, exercise, participate
in social activities, travel, sexual activities, etc? (If yes, which ones)
_______________________________________________________________________________
_______________________________________________________________________________

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

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Allergies: Please list them with the kind of reaction you get below.
Medication name Reaction Medication name Reaction

Medications: Please list names, doses and how often taken

Medication name Dose How often taken

MEDICAL PROBLEMS: Please circle Yes or No.

Diabetes Y N High blood pressure Y N Heart disease Y N Autoimmune Y N
problem
Kidney diseasse Y N Epilepsy / seizures Y N Psychiatric Y N Postpartum Y N
problems depression
Liver disease Y N Varicosities or Y N Thyroid disease Y N Trauma / Y N
phlebitis violence
Rh incompatibility Y N Asthma Y N Allergies Y N Breast problems Y N
Anesthesia Y N Abnormal paps Y N Uterine Y N Herpes Y N
problems anomaly / DES
Viral hepatitis Y N Gonorrhea Y N Chlamydia Y N HPV Y N
HIV/AIDS Y N Syphilis Y N Y N Y N

Other medical problems

_______________________________________________________________________________________

_______________________________________________________________________________________

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SURGICAL HISTORY:
Artificial reproductive treatment Y N Cesarean section Y N
Blood transfusion Y N

Other surgery ______________________________________________________________________________________

__________________________________________________________________________________________________

ADDITIONAL INFECTION HISTORY:

Live with someone with TB or exposed to TB (tuberculosis) Y N
Patient or partner has history of genital herpes Y N

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

SOCIAL HISTORY: please tell me about your habits.

Tobacco use: Please circle

Tobacco use: Yes Never Quit Passive exposure only
Packs a day: 1 1 2 2 _________ Years , 1, 2, 3, 4, 5, 10, 20, 30, 40,_______
Quit date: __________

Alcohol use: Please circle YES NO

_____ glasses of wine per week
_____ cans of beer per week
_____ shots of liquor per week
_____ drinks containing 0.5 oz of alcohol per week

Street drug use: Yes, No If yes, I use ______________________________________

Obstetric History:
Number of pregnancies _____ Number of deliveries ______ Full term deliveries _____
Preterm deliveries _____ Miscarriages _____ Elective abortions _____
Ectopic pregnancies _____ Multiple pregnancies _____ Currently living children _____

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REVIEW OF SYSTEMS: Please tell me if you have suffered from these conditions.
Please CIRCLE if you have had these , if not, please circle (none) at the end of the line
.
Constitutional: Fever, chills, weight loss, malaise/fatigue, fainting ________(none)
Skin: Rash, itching, dry skin _______________________________________(none_
Head and neck: headaches, hearing loss, ringing in ears, ear pain, ear discharge,
nosebleeds, congestion, stridor (difficulty breathing with something in throat), sore
throat, hoarse voice.____________________________________________(none)
Eyes: blurred vision, double vision, photophobia (cant stand light), eye pain, eye
discharge, eye redness.__________________________________________(none)
Heart and circulation: chest pain, palpitations, orthopnea (difficulty breathing when
lying down), claudication (pain in legs when walking), leg swelling, syncope
(passing out), difficulty breathing at night.__________________________(none)
Breathing: coughs, coughing up blood, sputum production, shortness of breath,
wheezing.____________________________________________________(none)
Intestinal: heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood
in stool, black tarry stools________________________________________(none)
Genitourinary: painful urination, abnormal urgency to urinate, urinating too much,
urinating too often, blood in urine._________________________________(none)
Muscles: pain in muscles, neck pain, back pain, joint pain, falls.____________(none)
Glands and blood: easy bruising or bleeding, seasonal allergies, drinking too much
water, eating too much.__________________________________________(none)
Nerves: tingling, tremors, sensation changes, speech changes, weakness in areas,
seizures.______________________________________________________(none)
Psychiatric: depression, wanting to hurt or kill yourself, wanting to hurt or kill
someone else, substance abuse, hallucinations, nervousness or anxiety, insomnia,
memory loss. _________________________________________________(none)

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