Let's get started
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
When was it?
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?
Was it normal?
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 (or anything you see a doctor for or take medications for).
Medications
Are you taking any medications?
Medication allergies
Are you allergic to any medications?
Allergies
Are you allergic to any of the following ingredients?
Is the basic info in your health profile still accurate?
Patient name
Buffy the Vampire Slayer
Allergies
None, cats, orange juice
Medications
None, vitamins, tylenol
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.
Has a medical provider evaluated and diagnosed the cause of your vaginal bleeding?
Any other information you'd like to share about the vaginal bleeding?
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?
If you currently have breast, uterine, ovarian or endometrial cancer, vaginal estradiol may still be safe for you to use. We just ask that you discuss and get approval from your oncologist.
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?
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?
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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.
The Title
The subtitle
What is your current weight?
lbs
What is your height?
feet inches
Blood pressure
Understanding your blood pressure is an important safety factor. What is the most recent reading you have?
systolic, mm Hg, upper # diastolic, mm Hg, lower #
Vaginal dryness
Do you have a sensation of dryness or burning in the vagina, difficulty with sexual intercourse?
Are you using a hormonal IUD?
Tobacco smoking habits
Are you using any tobacco products
Finish health profile
Enter your date of birth Month/Day/YYYY.
By submitting your health profile you agree to the Interlude Terms of Service, and Privacy Policy, and Consent to Telehealth.
Got it!
Are you sure you'd like to proceed?
Vaginal estradiol can help treat vaginal and urinary changes due to perimenopause and menopause. Would you still like to continue with a consult? There's a chance you're not a good candidate due to your age, and if so, we'll refund your medication fee, but not the consult fee.
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My care plan
Your care plan and prescription are just a few steps away. What's next?
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Meet your provider
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Today's summary
Get your prescription renewed for up to 1 year or 7 refills.
Vaginal estradiol 
Prescription renewal (one-time fee)
Reviewed by a board-certified doctor. Prescription valid for up to 1 year or 7 refills.
Payment method
The next step is to submit a new health profile. By clicking "Pay and continue" you authorize us to continue shipping refills at your selected frequency. Each refill is with free shipping.

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Email: support@getinterlude.com
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