Mona Lisa Screening

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Are you 45 years or older? *

Yes No

Daytime Contact Information *

How were you referred to us? *

Physician/other Clinician (please specify)

Physician/other Clinician (please specify) *

Choose One *

Friend Media Internet Other (please specify)

Other (please specify) *

Do you have a regular gynecologist? *

Yes (Please indicate name of gynecologist and approximate date of last visit) No, I do not have a regular gynecologist Other

Other (please specify) *

Have you been told by a health care practitioner that you have vulvovaginal atrophy, genitourinary syndrome of menopause, or vaginal thinning due to lack of estrogen? *

Yes No

If you have pain during intercourse? *

I do not have pain or do not have intercourse I have pain and it feels very dry I have pain but I do not feel dry

Are you currently using any over the counter products such as vaginal lubricants or moisturizers? *

Yes, but I still have pain with intercourse Yes, and it reduces or eliminates pain No

Are you currently using any of the following prescription products? *

Do you have any of the following urinary symptoms? *

Loss of urine with cough, laughs, sneeze or exercise Loss of urine because I sometimes do not get to the toilet quickly enough Frequent urinary tract infections Urinary urgency (feeling like I need to urinate) None of the above

Do you have other sexual or hormonal concerns? *

Do you have any of the following vulvar (external genitalia) symptoms or conditions? *

Do you have breast cancer? *

Yes No

Have you ever had pelvic or vaginal radiation? *

Yes No

Is there anything else you would like us to know? *

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Mona Lisa touch Pre-screening questionnaire