How long have you been experiencing vaginal symptoms?
Dryness
Does it feel like there is a lack of moisture or like the skin is sticking together?
How severe is it? Select one.
Soreness
Is your vagina or vulva sore or uncomfortable with ordinary daily activities like walking
and exercise?
How severe is it? Select one.
Irritation
Do you ever have a burning or itching sensation in your vagina or vulva?
How severe is it? Select one.
Pain with sex
Do you experience discomfort, pain, or bleeding during or after sexual activity or touch?
How severe is it? Select one.
Urinary health
Have you had more than three urinary tract infections in the last year?
Urinary health
Do you have more urgency to pee?
Other urinary symptoms
Are you experiencing any other urinary symptoms that your doctor should be aware of?
Why can't I proceed? You haven't reported any
symptoms related to vaginal atrophy. Please go back and check that you have reported
your
symptoms.
Urinary health
Would you like to have your urinary symptoms evaluated to determine if you currently need
treatment for an active UTI?
Got it!
We'll evaluate your symptoms for an active UTI at the end of this questionnaire.
Your last period
Hormonal shifts in perimenopause and menopause cause changes to the vulva, vagina, and
urinary tract.
When was your last period?
Do you experience any period irregularities?
Irregular periods may be a sign of perimenopause.
Select all that apply.
Have you had surgical removal of any of your reproductive organs?
Symptoms can be more acute in women who have their uterus and/or ovaries removed.
Select all that apply
Other genital symptoms
Are you experiencing any other genital symptoms that your doctor should be aware of?
Have you tried any previous therapies to address your genital symptoms?
Please include names of any treatments, if they were
effective and if you experienced any side effects.
Pelvic exam
When was your last pelvic exam?
Physician check up
When was your last check up with a physician?
Pelvic exam
Were any abnormalities found on your last pelvic exam?
Have you had a mammogram in the past 2 years?
Some medical conditions may make it unsafe for you to use topical estrogen.
Have you had any of the following medical conditions?
Medical conditions
Do you have any other diagnosed medical conditions? Please be sure to include any conditions
that may affect your genital health.
How is the vaginal estradiol working for you?
Vaginal bleeding
Vaginal bleeding outside of your normal menstrual cycle could indicate a serious condition
and should be assessed by an in-person examination from a primary care physician or
gynecologist. You will not be prescribed treatment until the condition is assessed.
Have you noticed any of the following symptoms? Select all that apply.
Pregnancy
Are you pregnant or planning to be pregnant?
Breastfeeding
Are you breastfeeding?
Cancer history
Do you have a history of breast, uterine, ovarian or endometrial cancer?
Cancer history
As someone with a history of breast, uterine, ovarian or endometrial cancer, has your
oncologist
counseled you about vaginal
estrogen?
Aromatase inhibitors
Are you taking any of the following aromatase inhibitor medications?
Other medications
Are you taking any medications?
Medication allergies
Are you allergic to any medications?
Allergies
Are you allergic to any of the following ingredients?
Part 2: Active UTI
Almost done! Next we'll evaluate your symptoms for an active UTI.
What urinary symptoms are you having?
Please read carefully. Select all that apply.
How many days ago did your urinary symptoms start?
How much distress/disruption of your daily activities are these urinary symptoms causing?
Have you ever had any of the following genitourinary issues?
Select all that apply.
Have you had any of the following?
Select all that apply.
Do you have a diagnosis of diabetes or a hemoglobin A1c >6.5%?
Does not include pre-diabetes.
What antibiotic did you take to treat your last urinary
tract infection?
How did you respond?
Have you had a urinalysis and/or urine culture done in the past year?
Is there anything else you think the doctor should know
about your urinary symptoms?
Do you understand all of the questions which were asked?
Same-day pickup
Choose a local pharmacy to pick up your active UTI medication.
Here's your first message to your doctor.
Please
introduce yourself and feel free to:
Here's a new message to your doctor.
Please feel free to:
Ask any questions you have.
List any medical problem you have which were not discussed above.
Include anything else you would like the doctor to know.
Please acknowledge that you understand and agree to the following
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.
Finish health profile
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start sending checkins from your medical provider. Please enter the code to continue.
Text/call (909) 378-6899 or email support@getinterlude for help
My care plan
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physician licensed in your state
must review a valid driver's license before prescribing treatment.
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visible, is not blurry, and is well-lit.
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My follow up
In order to refill your prescription, our medical team needs to
review your updated health profile to ensure that your treatment is still effective
and appropriate for you.
Vaginal estradiol
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Your online consult is reviewed by an MD and includes up to one
year of refills and unlimited messaging with your provider.
Your card will be charged today and
thereafter. You can cancel or
reschedule at anytime.
In the unlikely case that this treatment is no longer
appropriate for you, we will refund your payment in full.
Next step is to submit a new health profile
Today's summary
Get your prescription renewed for up to 7 more refills.
Vaginal estradiol
Prescription renewal (one-time fee)
Reviewed by a board-certified MD. Valid for up to 7
refills.
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profile. By clicking "Pay and continue" you authorize us to continue shipping
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