ThermiVa® Questionnaire
* = required fields
Patient Name
*
Email Address
Phone
*
Date of Birth
How would you rate your level of sexual desire?
1. Very low
2. Low
3. Moderate
4. Very High
Has your relationship with your partner been adversely affected due to childbirth or the natural aging process?
1. Definitely
2. Somewhat
3. Minimally
4. Not at all
How would you rate your sexual satisfaction during intercourse?
1. Poor
2. Fair
3. Good
4. Excellent
How confident are you about becoming aroused during sexual activity?
1. No confidence
2. Very low confidence
3. Moderate confidence
4. Very confident
Do you experience discomfort during intercourse due to dryness?
1. Yes, I avoid sex
2. Often
3. Sometimes
4. Rarely or never
Do you frequently experience urinary leaking or urgency?
1. Usually
2. Sometimes
3. Rarely
4. Never
How would you rate your vaginal tightness?
1. Very loose
2. Moderately loose
3. Moderately tight
4. Very tight
Comments
If you scored a 1 or 2 on any of the questions above or if you’d like more information, please submit this form and one of our staff will be in touch with you to schedule a consultation