Laser Vaginal Rejuvenation
07714466878
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07714466878
amishukla09@gmail.com
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Laser Vaginal Rejuvenation
Techniques We Use
MonaLisa Touch®
Conditions
Consent
Questionnaire
Contact Us
Questionnaire
1. Demographics
First Name
Last Name
E Mail
Age
Profession
Address
How many children have you had?
Menstrual History
Do you still have your periods?
Yes
No
If not, when did you stop your periods:
If you still have your periods, are they
Regular
Irregular
Heavy
Moderate
Light
Painful
No Pain
Do you have any other Gynaecological Conditions?
Are you upto date with your smear?
Are they all normal?
Medical history:
Surgical history:
Lifestyle factors (e.g., smoking, activity level)
Do you smoke ? If so how many?
Do you drink alcohol? How many units a day?
Next
2. Symptoms & Severity
Do you experience urinary leakage?
Yes
No
How frequently do you experience urinary urgency?
Never
Occasionally
Regularly
Daily
Very Often
Do you leak with urgency?
Yes
No
Do you leak with exertion?
Yes
No
Coughing
Sneezing
Walking
Running
Jumping
Sexual intercourse
Other
How many pads do you use every day?
1-3
4-6
>6
Do you experience pelvic organ prolapse symptoms?
Yes
No
Feeling of a lump in the vagina
Discomfort
Pain
Dragging sensation
Difficulty passing urine
Difficulty opening bowels
How would you rate your pain or discomfort?
Note: Scale 10 being the worse
1
2
3
4
5
6
7
8
9
10
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3. Impact on Daily Life
Do your symptoms affect your daily activities? (e.g., work, exercise, social life)
Has your condition impacted your mental health or emotional well-being?
How do you currently manage your symptoms? (Medication, exercises, surgery, lifestyle changes)
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4. Treatment Satisfaction & Needs
Have you received treatment for your condition?
Yes
No
Please describe the treatment already received for prolase or urinary symptoms
Pelvic floor exercises self directed
Pelvic floor exercises with physio therapist
Vaginal ring pessary
Vaginal oestrogen cream or pessary
Medications for urinary symptoms
If yes, how satisfied are you with the treatment?
Not at all
A little bit satisfied
Satisfied
Very Satisfied
What improvements would you like to see in your care?
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5. Urinary Symptoms
How frequently do you experience the following symptoms?
Urinary leakage
Never
Rarely
Sometimes
Often
Very Often
Urinary urgency
Never
Rarely
Sometimes
Often
Very Often
Pain or burning during urination
Never
Rarely
Sometimes
Often
Very Often
Changes in urine appearance (cloudiness, odor, blood)
Never
Rarely
Sometimes
Often
Very Often
Persistent urge to urinate
Never
Rarely
Sometimes
Often
Very Often
Recurrent urinary tract infections
Never
Rarely
Sometimes
Often
Very Often
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6. Vulval Symptoms
Do you experience vulval discomfort, pain, or itching?
Yes
No
How would you describe the sensation?
Burning
Itching
Soreness
Stabbing Pain
Other
Have you noticed any changes in skin appearance (e.g., redness, swelling, ulcers, discoloration)?
Yes
No
Do you experience pain during sexual activity or when inserting tampons?
Yes
No
How long have you been experiencing these symptoms?
Days
Weeks
Months
Years
Have you been diagnosed with a vulval condition (e.g., lichen sclerosus, vulvodynia, dermatitis)?
Yes
No
Have you sought medical advice for these symptoms?
Yes
No
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7. Sexual Function & Well-being
How frequently do you experience the following symptoms?
Discomfort during sexual activity
Never
Rarely
Sometimes
Often
Very Often
Decreased libido or sexual desire
Never
Rarely
Sometimes
Often
Very Often
Difficulty with arousal or orgasm
Never
Rarely
Sometimes
Often
Very Often
Intimacy or confidence affected
Never
Rarely
Sometimes
Often
Very Often
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8. Postpartum Perineal Health
Did you experience a perineal tear or episiotomy during childbirth?
Yes
No
If yes, how would you rate your recovery?
Poor
Moderate
Good
How frequently do you experience the following symptoms?
Perineal pain or discomfort
Never
Rarely
Sometimes
Often
Very Often
Numbness or hypersensitivity
Never
Rarely
Sometimes
Often
Very Often
Scar tissue discomfort
Never
Rarely
Sometimes
Often
Very Often
Impact on intimacy
Never
Rarely
Sometimes
Often
Very Often
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9. Vaginal Laxity & Sensation
Have you noticed a change in vaginal tightness or sensation?
Yes
No
If yes, how would you describe it?
Looser
Decreased sensation
Other
How frequently do you experience the following symptoms?
Difficulty retaining tampons
Never
Rarely
Sometimes
Often
Very Often
Pelvic muscle control issues
Never
Rarely
Sometimes
Often
Very Often
Impact on sexual confidence
Never
Rarely
Sometimes
Often
Very Often
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10. Lifestyle Factors
How much water do you typically drink daily?
Less than 1L
1–2L
More than 2L
How often do you consume caffeinated or carbonated beverages?
Never
Rarely
Sometimes
Often
Very Often
Do you smoke or use tobacco products?
Yes
No
How physically active are you?
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