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Questionnaire for Yeast Infection
Are you a female?
Are you currently pregnant?
Are you aged between 18 and 65?
Have you had more than four yeast infections in the last year?
Have you been diagnosed with a yeast infection in the past?
Have you had any bleeding outside of your normal cycle or after sex?
Do you currently have any sores, blisters or ulcers in or around your vagina?
Do you have an allergy (hypersensitivity) or had any adverse reactions to any medication?
Have you ever been told your kidneys are not working properly or are you currently receiving treatment for kidney disease?
Have you been advised that you have a prolonged QT interval on a ECG?
Do you have an allergy (hypersensitivity) or had any adverse reactions to any medication?
Currently taking any medications? This includes over-the-counter, prescriptions and recreational drugs.
Do you agree with the folllowing statement below?

You will contact us if you experienced side effects from the treatment, start new medication or
develop or have a change in your medical condition.


The treatment is solely for you in your own use.


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly, and that incorrect information can be hazardous to your health.


You will read the patient information leaflet supply with your medication.


You will notify your primary care physician about your treatment from PBJ medical associates.

Thanks. We'll get back to you soon.

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