Name
*
First Name
Last Name
Date Of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Is the discharge greyish or white in colour?
*
Is there a fishy or unpleasant odour?
*
Yes
No
Do you have any itching, soreness or burning?
*
Yes
No
Are you experiencing pain during sex?
*
Yes
No
Not Applicable
Are you experiencing pain when passing urine?
*
Yes
No
How long have these symptoms been present?
*
Less than 1 week
1–2 weeks
More than 2 weeks
Have you had BV before?
*
Yes
No
Have you recently used any vaginal washes, douches, or perfumed products?
*
Yes
No
Have you experienced bleeding between periods or after sex?
*
Yes
No
Do you have lower abdominal pain or fever?
*
Yes
No
Have you been diagnosed with an STI in the past year?
*
Yes
No
Are you currently pregnant or could be pregnant?
*
Yes
No
Have you had any recent vaginal procedures or IUD insertion?
*
Yes
No
Have you previously been treated for BV?
*
Yes
No
If yes, which treatment(s) did you use and how long ago?
Did the treatment work at the time?
*
Yes
No
Are you currently taking any prescription or over-the-counter medications?
*
Yes
No
Please list your current medications
Do you have any known allergies to medications (e.g., metronidazole, clindamycin)?
*
Yes
No
If yes, please specify
Do you have any liver disease, blood disorders, or neurological conditions (e.g., epilepsy)?
*
Yes
No
Do you drink alcohol daily or frequently?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Are you taking anticoagulants, lithium, or medications that interact with antibiotics?
*
Yes
No
Are you registered with a GP?
*
Yes
No
GP Surgery Name
Would you like us to notify your GP of this consultation?
*
Yes
No
Consent & Declaration
*
