Intimate Wellness History Update

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Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

When was your last intimate wellness procedure?

What procedure/s did you have done?

What results did you see?

If you are postmenopausal, are you on hormone replacement?

What hormones are you taking?

Have you had any surgeries since we last saw you?

If yes, please list your surgeries and the year

Please check off any if you have any of these medical conditions

Are you on any medications?

Please list your medications

Please list your supplements

What are you wanting to improve? *

Has your libido changed?

Have you had a GYN exam and Pap smear in the past year?

Was it normal?

Please give more detail on any GYN concern you may have had recently have ie pain with sex, vaginal discharge, infection or heavy bleeding.

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