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Physician Diagnosis Questionnaire

Questions

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Initial Questions:

Is this your first breakout?
Where on your body are you currently experiencing symptoms? Choose all that apply.
When did the symptoms start?
What symptoms are you currently experiencing? Choose all that apply.
Do you have a kidney or liver condition that prevents you from taking prescription medication?
Do you have any known allergies to prescription medications?
Are you currently pregnant or could you be pregnant?
Do you have any major or relevant medical conditions that the physician should be aware of?
When was your last outbreak?
Approximately how many outbreaks have you had in your life time?
Are you taking any prescription medication?
Are you taking any prescription medication for herpes now?
Are you taking any over-the-counter medications for herpes now?
Have you previously taken any prescription medication for herpes?
Is there any additional information that you would like your physician to be aware of?
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    Diagnosis Cost: $79.99



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