Genital Herpes - WePrescribe

Genital Herpes Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Have you ever been previously diagnosed by a GP or GUM clinic with genital herpes?

Do you currently have symptoms of genital herpes? This includes some of the following;

- 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?

Have you suffered with more than 6 repeat episodes of genital herpes within the last 12 months?

Are you currently experiencing any of the following symptoms?

- 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?

This can include: -Immune system conditions such as HIV -Liver or kidney issues

Please provide more details

Do you suffer with any allergies?

If so, please provide more information

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Do you currently take any medication? This includes herbal remedies and over the counter medication.

If so, please provide more information

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Are you currently pregnant, planning a pregnancy or breastfeeding?

Is there any other information you would like to share with our prescribing team?

If so, please provide more information

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We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

Genital Herpes Consultation

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