O-Shot Self Test

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Take Our O Shot Self Test

Date / Time

Date

Time

Name *

First

Last

Email *

Phone *

What is your date of birth?

When was your last menstrual period?

Have you been through menopause?

Yes
No

If you are postmenopausal, are you on hormone replacement?

Yes
No

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

Diabetes
Hypertension
Autoimmune condition
Low thyroid
History of cancer
Heart disease
Other

Please list any other medical conditions you have

Are you on any medications?

Yes
No

Please list your medications

Are you having issues with achieving orgasm?

Yes
No

Is sex less enjoyable?

Yes
No

Do you have vaginal dryness?

Yes
No

If yes, how long have you had it. Have you tried anything?

Do you have bladder leaking?

Yes
No

Please check off if true for you,

I leak with coughing or sneezing
I have to rush to the bathroom
I have to wear pads due to leaking
I limit your water intake because of concerns about leaking
I leak without warning
I avoid exercise because of concern about leaking
I limit outings because of concerns you may lean

Have you had any surgeries?

Yes
No

Please list any surgeries that you have had.

Has your libido changed?

Yes
No

Was there a time when sex was more enjoyable?

Yes
No

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

Yes
No

Do you have any children?

Yes
No

If yes, did you have any difficult deliveries or larger babies?

Yes
No

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

Are you ready to book your Virtual Consultation? If yes, book here https://tinyurl.com/2p8uzx3u. Must copy and paste link.

Yes
No

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