Genital Herpes Consultation Are you a female?
- Select - Yes No
Have you ever been previously diagnosed by a GP or GUM clinic with genital herpes?
- Select - Yes No
Do you currently have symptoms of genital herpes? This includes some of the following;
- Select - Yes No
- Painful blisters in the genital area
- Blisters that have become erosions or ulcers in the genital area
- Tingling pain in the genital area, lower back, buttocks or legs
Have you ever previously been treated for genital herpes?
- Select - Yes No
Have you suffered with more than 6 repeat episodes of genital herpes within the last 12 months?
- Select - Yes No
Are you currently experiencing any of the following symptoms?
- Select - Yes No
- Blood in your stools or urine
- Unintentional weight loss
- Night sweats
- Fever
- Pain when passing urine
- Genital discharge
Have you ever been diagnosed with any other medical conditions?
- Select - Yes No This can include:
-Immune system conditions such as HIV
-Liver or kidney issues
Please provide more details
Do you suffer with any allergies?
- Select - Yes No If so, please provide more information
Please provide more details
Do you currently take any medication? This includes herbal remedies and over the counter medication.
- Select - Yes No If so, please provide more information
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Are you currently pregnant, planning a pregnancy or breastfeeding?
- Select - Yes No
Is there any other information you would like to share with our prescribing team?
- Select - Yes No If so, please provide more information
Please provide more details
We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?
- Select - Yes No
- Select - Yes No
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