THIS HISTORY FORM HELPS US TO KNOW MORE ABOUT YOU AND MAKE THE BEST RECOMMENDATIONS FOR YOU. THANK YOU FOR FILLING IT OUT. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is your date of birth MM-DD-YEAR?How did you hear about the O shot , Vampire Winglift or Clitoxin?Are you still having periods? *YesNoIf you are still having periods, are they still regular?Have you been through menopause? *YesNoHave you had a hysterectomy?YesNoIf you have had a hysterectomy, do you still have your ovaries?YesNoIf you are postmenopausal, are you on hormone replacement?YesNoHave you had any surgeries? YesNoIf yes, please list your surgeries and the yearPlease check off any if you have any of these medical conditionsDiabetesHypertensionAutoimmune conditionLow thyroidHistory of cancerHeart diseaseOtherPlease list any other medical conditions you haveAre you on any medications?YesNoPlease list your medicationsPlease list your supplementsDo you have any drug allergies?YesNoIf yes, what are they?Do you smoke cigarettes? *YesNoIf yes, how many do you smoke a day?Do you drink alcohol?YesNoIf yes, how much do you drink per week?The O shot uses PRP injections to improve Intimate Wellness for women. It can help with dryness, leaking and orgasm. The Vampire winglift uses filler combined with PRP for injecting the labia majora. Clitoxin helps with arousal and desire. What are you wanting to see improve? *Vaginal drynessBladder leakingSexual functionImproved vaginal/vulvar healthImproved sensationImproved sensation externallyMore fullness in the labia majoraMore youthful appearance to the vulbaImprove arousalIf you have bladder leaking, please check off if true for you,I leak with coughing or sneezingI have to rush to the bathroomI have to wear pads due to leakingI limit my water intake because of concerns about leakingI leak without warningI avoid exercise because of concern about leakingIf you answered yes to any of the above questions, how long have you had the concerns? Is there anything that you have tried to help?Is sex less enjoyable now?YesNoWas there a time when sex was more enjoyable?YesNoAre you having issues with achieving orgasm?YesNoHas your libido changed?YesNoHave you had your testosterone level checked?YesNoHave you tried anything to help?Have you had any surgeries?YesNoPlease list your surgeriesHave you had a GYN exam and Pap smear in the past year?YesNoWas it normal?YesNoDo you have any children?YesNoIf yes, did you have any difficult deliveries or larger babies?YesNoDid you have any bad tears with vaginal deliveriesYesNoPlease give more detail on any GYN concern you may have had recently have ie pain with sex, vaginal discharge, infection or heavy bleeding.We want to make the most of your time and the doctors'. Have your read the site and learned about the procedures and the Pricing options?YesNoCan we text you?YesNoProve you are human-Custom Captcha * = SUBMIT ← Back to home page of website
