Support Assessment

"*" indicates required fields

Step 1 of 13

1/10: Nuts and bolts

Email Address*

Name*

First Last

Date of Birth*

Year

Month

Day

Age*

Country*

Select

Height*

Weight*

I gender identify as*

I have a*

Vagina

Neo Vagina

Penis

Neo Penis

It's complicated (Fill us in later!)

2/10: What's up!

How can we help you? Ask your question!*

3/10: About your urogenital symptoms

I have vaginal/penile symptoms*

Yes

My recent vaginal/penile symptoms include:*

Abnormal discharge

Odour

Itching

Pain

Burning

Redness

Other

Dryness

Skin/tissue changes

I do not have symptoms

Odour*

Fishy

Ammonia

Vinegar

Foul

Rotten meat

Faeces (poo)

Musty

Sour

Discharge*

Watery

Thick

Cottage-cheese (lumpy)

Stringy

Pasty

Sticky

Frothy

White/creamy

Greyish

Greenish or yellowish

Brownish

Clear

Discharge varies

The pain is around the:*

Vulva (outside)

Clitoris/clitoral hood

Vagina (inside)

Ovaries

Fallopian tubes

Uterus

Perineum

Anal area

Pelvic area

Pain moves

Penis - glans (head)

Penis - shaft

Scrotum

Prostate

Cervix

Other

The itch is around the:*

Vulva (outside)

Vagina (inside)

Anal area

Itch moves

Penis - glans (head)

Penis - shaft

Scrotum

Please explain other symptoms*

I have urinary tract symptoms*

Yes, currently

Yes, sometimes

No, never

Not right now, but in the past

My urinary tract symptoms include*

Frequency

Urgency

Stinging

Burning

Bladder pressure

Twinges or spasms

Strong-smelling urine

Fear being away from bathroom

Urinary tract symptoms worsen closer to my period

Incontinence (involuntary urine leaks)

Other - please describe

Explain your other urinary tract symptoms

So far, treatments I have tried include:*

Lactulose

Fluomizin

Manuka Honey

Chanel Pessary

AV Herbal Pessary Blend

BV Herbal Pessary Blend

Ureaplasma Herbal Pessary Blend

Vaginal InterFase Plus

Oral Enzymes (Nattokinase, Serralase, Kirkman's Biofilm Defense, InterFase Plus)

Milk Kefir

Probiotics

Lactoferrin

Ozonated Oil

Vaginal Garlic

Boric Acid

Oral Antibiotics

Vaginal Antibiotics

Other treatments

Please list other treatments*

Please list treatments tried so far and their outcomes:*

I have been tested for sexually transmitted infections*

Yes

I'm not sure

I use a condom/barrier when I have sex*

Always

Most of the time

Some of the time

Never

I'm not sexually active

During my period, my symptoms*

Worsen

Improve

Stay the same

I don't get periods

Vaginal pH*

N/A

I don't know

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5+

In the past year, a medical doctor has diagnosed me with:*

Bacterial vaginosis

Aerobic vaginitis

Cytolytic vaginosis

Yeast infection

Urinary tract infection

Pelvic inflammatory disease

A sexually transmitted infection

I have not been formally diagnosed with anything

I have symptoms but a test comes back clear

Something else

Please explain*

Across my life, I have a history of*

Bacterial vaginosis

Aerobic vaginitis

Cytolytic vaginosis

Yeast infection

Urinary tract infection

Pelvic inflammatory disease

A sexually transmitted infection

I have not been formally diagnosed with anything

I have symptoms but a test comes back clear

Something else

None

Please explain*

I have had symptoms for*

Less than 6 months

Less than 1 year

More than 1 year

More than 2 years

More than 5 years

More than 10 years

As long as I can remember

What do you think triggered your symptoms initially?*

4/10: A little bit of context

Do you have any allergies? Hayfever, pets, medicine, food, environmental

Please list medical diagnoses and underlying conditions

Have you ever been hospitalised or had surgery?

Did you have any major illnesses as a child or teenager?

Please give a quick overview of trends in biological family health if known (kidney stones, diabetes, blood pressure, genetic health markers, UTIs, allergies, autoimmune, thyroid, etc.)*

I have used/am using Accutane (isotretinoin) acne drug*

Yes, in the past

Yes, using now

Never used

Planning to use in future

I regularly use antihistamine medication*

Yes

Don't need

I use asthma medication*

Yes

Don't need

5/10: What you're putting in

What medication, birth control, herbs, vitamins/minerals, or supplements are you currently taking? If none, please say so.*

What sort of physical movement or exercise do you regularly do?*

Describe your diet*

I have a very healthy diet

I try to eat well most of the time

I eat well some of the time

I don't care about my diet

I follow a very strict eating regime

I have a history of disordered eating

This field is hidden when viewing the form

Describe your diet

I have a very healthy diet

I try to eat well most of the time

I eat well some of the time

I don't care about my diet

I follow a very strict eating regime

I dabble or have dabbled in disordered eating

I mostly eat*

I eat everything

Low FODMAP

Paleo

Intermittent fasting

Anti-inflammatory protocol

Vegetarian

Vegan

Flexitarian (mostly plant-based)

Ketogenic

Calorie-controlled

Low oxalate

Low histamine

Gluten-free

Dairy-free

Low-GI

Other

Please explain other*

6/10: What you're getting out

Do you experience digestive issues on a regular basis?*

Yes

Please explain your digestive issues in more detail:

7/10: The invisible forces

Talk us through your energy levels (waxing and waning through the day, napping, fatigue, energy levels out of 10, 10 being the most energy)*

Talk us through how you sleep (bedtime, wake time, night terrors/paralysis, vivid dreams, no dreams, frequent waking, hard to drop off, etc.)*

Talk us through your anxieties and stressors (kids, parents, work, relationships, friendships, mental, emotional and spiritual health)*

8/10: Understanding your hormonal cycles

What most accurately describes your menstrual status?*

Never menstruated

Regular natural menstrual cycles

Irregular natural menstrual cycles

Using hormonal birth control (including hormonal IUD)

Using copper IUD (Paragard)

Perimenopausal

Naturally postmenopausal

Prematurely or medically postmenopausal

Tubal ligation

One or both ovaries removed

One or both fallopian tubes removed

Using hormone therapy

Pregnant

Breastfeeding

Postpartum

Actively trying to conceive

Please provide a little more information on your menstrual status response*

E.g. how long for, any changes to menstraul patterns/symptoms before/after, type of surgery, etc.

Hormonal birth control*

IUD (Mirena, Kyleena, Liletta, and Skyla)

The combined oral contraceptive pill

Low oestrogen combined pill

Mini pill (progestin only)

Injection

Ring

Sponge

Diaphragm

Patch

What most accurately describes your menstrual patterns?

Not getting periods

Spotting before period

Spotting mid menstrual cycle, ovulation spotting

Spotting after period

Heavy periods

Periods neither heavy nor light

Light periods

Long periods

Periods not long or short

Short periods

No pain during periods

Some pain during periods

Cramping before period starts

Painful periods

Watery blood

Lots of clots

Periods cause nausea

Periods send me to bed

Full menstrual cycle (day 1 of period to day 1 of next period) regularly over 35 days

Full menstrual cycle (day 1 of period to day 1 of next period) regularly less than 21 days

Full menstrual cycles (day 1 of period to day 1 of next period) tend to be the same each cycle, regular

How many days does your period (menstrual bleeding) usually last?

e.g 2, 5, 7 or 5-7

How many days are your full menstrual cycles, from Day 1 of your period to Day 1 of your next period?

Usually 20-35 days, but may be longer or shorter. This is NOT your period.

Premenstrual symptoms include:

Tender breasts

Mood changes (depression, anxiety, sadness)

Easily irritated or teary

Digestive disturbances

Period headaches/menstrual migraines

Food/sugar cravings

Premenstrual dysphoric disorder (PMDD)

I have been diagnosed with or suspected of having:

Endometriosis

Polycystic ovarian syndrome (PCOS)

Fibroids

MCAS

Ehlers-Danlos Syndrome (EDS), hypermobility

Breast cancer

Ovarian cancer

None

8/10: Crunching the numbers

Microbiome test*

I do not have a microbiome test

I am uploading a test here

I have added info@myvagina.com to my Juno dashboard

Upload recent microbiome tests

Drop files here or

Max. file size: 12 GB.

JUNO NOTE: if you have a Juno report, please visit your dashboard (app.juno.bio), click the share symbol, and add info@myvagina.com to share your results with My Vagina.

Password for protected PDFs

Upload raw DNA .zip file from MyHeritage, 23andme or Ancestry.com

Accepted file types: txt, zip, Max. file size: 12 GB.

We can screen your DNA test for a handful of key markers These results are only used for support purposes. Please log into your provider's website and download the raw data file and upload here.

9/10: Almost there!

Snapshot of your world*

Super busy

Relaxed pace

Stressed out

Just feeling crazy

Other

Please explain how you're feeling*

Do you have any barriers to treatment? (tight budget, allergies, disability, full schedule, lots of travel, etc)

Anything else we need to know about you?

10/10: Well done! Just one last thing...

Consent to disclaimer*

Yes I agree!

Please note this disclaimer is a complex legal document. It essentially means that outside of Australia (where we are bound by Australian law) My Vagina and its practitioners and staff are not legally responsible for what happens to you and you engage with us and follow our recommendations at your own risk.

In saying this, we are qualified practitioners operating within the legal framework of Australia, and we take this very seriously! We will work hard for you within our capabilities and provide a high level of care.

MISCELLANEOUS LIMITATION OF LIABILITY
The client agrees they use My Vagina’s services at their own risk.

Client releases My Vagina, its officers, employees, directors, subsidiaries, principals, agents, heirs, executors, administrators, successors, assigns, instructors, guides, staff, participants, naturopaths, practitioners and related entities any way as well as the venue where the sessions are being held (if applicable) and any of its owners, executives, agents, or staff (hereinafter “Releasees”) from any and all damages that may result from any claims arising from any agreements, all actions, causes of action, contracts, claims, suits, costs, demands and damages of whatever nature or kind in law or in equity arising from my participation in the consultations.

Client accepts any and all risks, foreseeable or unforeseeable.

Client agrees that My Vagina will not be held liable for any damages of any kind resulting or arising from including but not limited to; direct, indirect, incidental, special, negligent, consequential, or exemplary damages happening from the use or misuse of My Vagina’s services or enrolment in the Program.

My Vagina assumes no responsibility for errors or omissions that may appear in any of the materials.

JURISDICTION
Your use of the My Vagina website and services and any dispute arising out of your use of it is subject to the laws of the Commonwealth of Australia.

These terms are governed by the laws of the Commonwealth of Australia and subject to the exclusive jurisdiction of the courts operating in Australia.

My Vagina’s website and resource materials may be accessed throughout Australia and overseas.

We make no representation that My Vagina’s website complies with the laws (including intellectual property laws) of any country outside Australia.

If you access My Vagina’s website from outside Australia, you do so at your own risk and are responsible for complying with the laws in the place where you access My Vagina’s website and services.