Go back to home page of the site Please enable JavaScript in your browser to complete this form.Take Our O Shot Self TestDate / TimeDateTimeName *FirstLastEmail *Phone *What is your date of birth? *How did you hear about the O shot?When was your last menstrual period?Have you been through menopause?YesNoIf you are postmenopausal, are you on hormone replacement?YesNoPlease 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 medicationsAre you having issues with achieving orgasm?YesNoIs sex less enjoyable?YesNoDo you have vaginal dryness?YesNoIf yes, how long have you had it. Have you tried anything?Do you have bladder leaking?YesNoPlease 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 your water intake because of concerns about leakingI leak without warningI avoid exercise because of concern about leakingI limit outings because of concerns you may leanHave you had any surgeries?YesNoPlease list any surgeries that you have had. Has your libido changed?YesNoWas there a time when sex was more enjoyable?YesNoHave you had a GYN exam and Pap smear in the past year?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.Are you ready to book your Virtual Consultation? If yes, book here https://tinyurl.com/2p8uzx3u. Must copy and paste link. YesNoProve you are human-Custom Captcha * = SUBMIT ← Back to home page of website
