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My Vagina Support
Articles
Infections
Aerobic vaginitis (AV)
Bacterial Vaginosis (BV)
Understanding and treating urinary tract infections (UTIs) and cystitis
Vaginal yeast infections and thrush
Treatments
Treat BV naturally
How to treat vaginal fissures – cracks, cuts and tears
BV Research
My Vagina’s Blog
Aunt Vadge
Ask Aunt Vadge
Schedule Consultation
My Programs
All Programs
Killing BV – Vagina
Perimenopause Survival Kit
Practitioner
Apply for Practitioner Access
Practitioner Support Intake Form
Practitioner Support - Patient Information Assessment
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Step
1
of
10
10%
1/10: Nuts and bolts
Your Email Address
*
Enter Email
Confirm Email
Your Name
*
First
Last
Phone number with country code (in case of connectivity issues)
*
Patient Information
Age
*
Country
*
Gender identity
*
Patient has:
*
Don't know
Vagina
Neo Vagina
Penis
Neo Penis
It's complicated (fill us in later!)
Approximate BMI
*
Don't know
Underweight
Tends to underweight
Within normal weight ranges
Tends to overweight
Overweight
Obese or morbidly obese
2/10: Goals
What is your patient trying to achieve?
*
3/10: The vagina and urinary tract
Urinary tract symptoms
*
Don't know
Yes, currently
Yes, sometimes
No, never
Not right now, but in the past
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 other urinary tract symptoms
Vaginal symptoms
*
Don't know
Yes
No
Does not have a vagina
Previous treatments and their outcomes, if known
*
During menstruation, symptoms:
*
Don't know
Worsen
Improve
Stay the same
Not getting periods
Vaginal symptoms include:
*
Don't know
Abnormal discharge
Odour
Itching
Pain
Burning
Redness
Dryness
Skin/tissue changes
Other
No symptoms
Please explain other symptoms
*
Odour
*
Don't know
Fishy
Ammonia
Vinegar
Foul
Rotten meat
Faeces (poo)
Musty
Sour
Discharge
*
Don't know
Watery
Thick
Cottage-cheese (lumpy)
Stringy
Pasty
Sticky
Frothy
White/creamy
Greyish
Greenish or yellowish
Brownish
Pinkish
Bloody
Clear
Copious
Discharge varies
The pain is around the:
*
Don't know
Vulva
Vagina
Clitoris/clitoral hood
Ovaries
One or both fallopian tubes
Uterus
Bladder
Perineum
Anal area
Pelvic area
Pain moves
The itch is around the:
*
Don't know
Vulva
Vagina
Anal area
Itch moves
Other
Vaginal pH
*
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, the patient has been diagnosed with:
*
Don't know
Bacterial vaginosis
Aerobic vaginitis
Cytolytic vaginosis
Yeast infection
Urinary tract infection
Pelvic inflammatory disease
A sexually transmitted infection
Not been formally diagnosed with anything
Has symptoms but a test comes back clear
Something else
Please explain
*
Patient has a history of
*
I don't know
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
*
Patient has 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 seemed to trigger symptoms initially?
*
4/10: A little bit of context
Allergies
Medical diagnoses and underlying conditions
Surgeries or hospitalisations
Major illnesses as a child or teenager
Trends in biological family health if known (kidney stones, diabetes, blood pressure, genetic health markers, UTIs, allergies, autoimmune, thyroid, etc.)
Patient has used Accutane (isotretinoin) acne drug
*
Don't know
Yes, in the past
Yes, using now
Planning to use in future
Not used
Patient uses antihistamine medication
*
Don't know
Every day
Every week
Every month
Only at certain times of the year
Never use
5/10: What's going in
Please list medication, birth control, herbs, vitamins/minerals, or supplements patient is taking
*
Regular physical movement or exercise
Diet
*
Don't know
Very healthy diet
Tries to eat well most of the time
Eats well some of the time
Doesn't care about diet
Follows a very strict eating regime
Disordered eating (past or present)
Diet choices
*
Don't know
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: Digestive
Are there digestive symptoms?
*
Don't know
Yes
No
Please explain digestive issues in more detail:
7/10: The invisible forces
Energy levels
*
Don't know
Tend to 8-10/10
Tend to 6-7/10
Tend to 4-5/10
Tend to 3/10 or less
Sleep quality
*
Don't know
Generally good, no issues with sleep
Difficulty falling asleep
Wakes early, can't get back to sleep
Disrupted sleep
Light sleep
Regular night terrors, nightmares
Heavy sleeper
Stress and anxiety levels
*
Don't know
No issues with stress or anxiety
High stress
High anxiety
Moderate stress
Moderate anxiety
Low stress
Low anxiety
8/10: Hormonal cycles
Menstrual status
*
Don't know
Never menstruated/physically unable to
Regular natural cycles
Irregular natural cycles
Using hormonal birth control (including hormonal IUD)
Using copper IUD (Paragard)
Perimenopausal
Naturally menopausal
Prematurely or medically menopausal
Tubal ligation
One ovary removed
Both ovaries removed
One fallopian tube removed
Both fallopian tubes removed
Using hormone therapy
Pregnant
Breastfeeding
Postpartum
Actively trying to conceive
Hormonal birth control
IUD (Mirena, Kyleena, Liletta, and Skyla etc)
The combined oral contraceptive pill
Low oestrogen combined pill
Mini pill (progestin only)
Injection
Ring
Patch
Other
Menstrual patterns
Don't know
Not getting periods
Spotting before period
Spotting mid cycle, ovulation spotting
Spotting after period
Heavy 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
Clotty periods
Periods cause nausea
Periods send me to bed
Full menstrual cycle regularly over 35 days
Full menstrual cycles tend to be the same each cycle, regular
Full menstrual cycle regularly less than 21 days
Days menstruating
Full menstrual cycle length
Premenstrual symptoms include:
Don't know
Tender breasts
Mood changes (depression, anxiety, sadness)
Easily irritated or teary
Digestive disturbances
Headaches before or during period
Menstrual migraines
Food/sugar cravings
Premenstrual dysphoric disorder (PMDD)
Fatigue
Insomnia
Diagnosed with or suspected of having:
None
Endometriosis
Polycystic ovarian syndrome (PCOS)
Fibroids
Mast Cell Activation Syndrome (MCAS)
Ehlers-Danlos Syndrome (EDS)
Breast or ovarian cancer
Gout
Gilbert's syndrome
Bowel conditions (IBS, SIBO, UC, etc.)
Kidney stones
8/10: Crunching the numbers - please obtain patient consent before sharing files
My patient has provided consent to securely share their files
*
Yes
I have deidentified the files
Your patient files are held in strictest confidence according to Australian law, held securely and deleted after the consultation. My Vagina DOES NOT keep non-patient healthcare files on record, but DOES keep consultation notes on the patient and practitioner for our records.
Upload recent vaginal and urinary microbiome tests
Drop files here or
Select files
Max. file size: 12 GB.
All your patient files are deleted after the consultation, however a file will be created with the notes of the consultation.
Upload recent blood tests, original PDFs from providers/labs (no screenshots)
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 12 GB.
Upload raw DNA .zip file from MyHeritage, 23andme or Ancestry.com
Drop files here or
Select files
Accepted file types: zip, Max. file size: 12 GB, Max. files: 1.
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. Only accepted format is .zip.
9/10: Almost there!
Anything else to add?
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 or your patients, 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 and your patients 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.
INFORMATION PROVIDED
All your personal and private medical information will be kept confidential under Australian medical laws.
We will use your information to improve your care using a variety of tools.
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.
Search for:
Shop
My Vagina Support
Articles
Infections
Aerobic vaginitis (AV)
Bacterial Vaginosis (BV)
Understanding and treating urinary tract infections (UTIs) and cystitis
Vaginal yeast infections and thrush
Treatments
Treat BV naturally
How to treat vaginal fissures – cracks, cuts and tears
BV Research
My Vagina’s Blog
Aunt Vadge
Ask Aunt Vadge
Schedule Consultation
My Programs
All Programs
Killing BV – Vagina
Perimenopause Survival Kit
Practitioner
Apply for Practitioner Access
Login
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