Questionair 2

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Questionair 2

NAME:

ADDRESS:

PHONE:

QUESTIONNAIRE ABOUT POSSIBLE ALLERGY TO SEMEM

1. How long have you had the problem? A.months. B.year

2. Do you have the problem exclusively with your current sexual partner? A.YES B.NO

3. If not, bow many times have you experience a reaction with other sexual partners?

4. Did you have the reaction on your first intercourse? A.YES B.NO

5. If the answer to the above is no, how many years after your first intercourse did the first reaction occur?

6. Prior to the first reaction did you have:

A.a recent pregnancy

B.recent gynecologic operation

C.other gynecologic problem

7. How soon after intercourse do your reactions occur? A.minutes B.Hours C.Days

8. How long after intercourse do your reactions last? A.minutes B.Hours C.Days

9. Do you have the following symptoms?

A)Generalized itching	YES NO	B)Hives	YES NO
C)Chest tightness	YES NO	D)Shortness of breath	YES NO
E)cough	YES NO	F)Wheezing	YES NO
G)Dizziness	YES NO	H)Faintness	YES NO
I)Complete collapse (shock)	YES NO	J) Unconsciousness	YES NO

10. If your symptoms are localized only to the vaginal tissue and surrounding areas, do you have symptoms of:

A)Deep pain	YES NO	B)Burning	YES NO
C)Redness	YES NO	D)Rash	YES NO
E)Blisters	YES NO

11. Does the use of condoms prevent the reaction? A. YES B.NO

12. How old are you now?

13. How old were you when the reaction first began?

14. Do you have other types of allergies such as asthma, hay fever, hives or eczema?A.YES B.NO

15. Do you have allergy to foods? A.YES B.NO

16. If so, which one(s)?

17. Do you have allergy to drugs? A.YES B.NO

18. If so, which one(s)?

19. Does anyone in your family have a history of hay fever, asthma, eczema or hives? A.YES B.NO

20. Have you been treated for this condition before?A.YES B.NO

21. If so, what types of treatment have you had?

22. Have you had any prior evaluation about the possible allergic aspects of your problem? A.YES B.NO

23. Have you had vaginitis due to Candida?A.YES B.NO

24. Do you wish to be evaluated by our medical group?A.YES B.NO

25. What is the name and address of the physician who has been treating you most recently for your problem?

NAME:

ADDRESS:

PHONE:

(Q-SP. ltr)

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