How long have you been experiencing vaginal symptoms?

Does it feel like there is a lack of moisture or like the skin is sticking together?

How severe is it? Select one.

Is your vagina or vulva sore or uncomfortable with ordinary daily activities like walking and exercise?

How severe is it? Select one.

Do you ever have a burning or itching sensation in your vagina or vulva?

How severe is it? Select one.

Do you experience discomfort, pain, or bleeding during or after sexual activity or touch?

How severe is it? Select one.

Have you had more than three urinary tract infections in the last year?

Do you have more urgency to pee?

Are you experiencing any other urinary symptoms that your doctor should be aware of?

Would you like to have your urinary symptoms evaluated to determine if you currently need treatment for an active UTI?

We'll evaluate your symptoms for an active UTI at the end of this questionnaire.

Hormonal shifts in perimenopause and menopause cause changes to the vulva, vagina, and urinary tract.

When was your last period?

Irregular periods may be a sign of perimenopause.

Select all that apply.

Symptoms can be more acute in women who have their uterus and/or ovaries removed.

Select all that apply

Are you experiencing any other genital symptoms that your doctor should be aware of?

Please include names of any treatments, if they were effective and if you experienced any side effects.

When was your last pelvic exam?

When was your last check up with a physician?

Were any abnormalities found on your last pelvic exam?

Have you had any of the following medical conditions?

Do you have any other diagnosed medical conditions? Please be sure to include any conditions that may affect your genital health.

Have you noticed any of the following symptoms? Select all that apply.

Are you pregnant or planning to be pregnant?

Are you breastfeeding?

Do you have a history of breast, uterine, ovarian or endometrial cancer?

As someone with a history of breast, uterine, ovarian or endometrial cancer, has your oncologist counseled you about vaginal estrogen?

Are you taking any of the following aromatase inhibitor medications?

Are you taking any medications?

Are you allergic to any medications?

Are you allergic to any of the following ingredients?

Almost done! Next we'll evaluate your symptoms for an active UTI.

Please read carefully. Select all that apply.

Select all that apply.

Select all that apply.

Does not include pre-diabetes.

Choose a local pharmacy to pick up your active UTI medication.

I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me. I understand all the questions that have been asked of me. The information that I have provided is accurate and complete. I am the patient who is consenting to be evaluated for treatment.