Has a certified medical practitioner examined you with genital herpes?
If you answered no, please explain how you discovered you have genital herpes.

Yes

No

Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Your doctor has ever told you that your kidney function is less than 100 percent.
You have previously suffered a terrible reaction to aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
You want to use Ibuprofen Gel on skin that is fractured, injured, diseased, or infected.

Yes

No

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or using any medication?

Please provide more information of the medication being used if any.

Yes

No

Can you relate to the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have a cardiovascular condition or have suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Do you have a history of using Instillagel tablets to cure a herpes infection?
If so, how successful were they?
If not, what treatment did you employ to get rid of your previous outbreak?

Yes

No

Are you experiencing any of the following problems?
Anaemia.
Deficiency in glucose-6-phosphate dehydrogenase.
Methaemoglobinaemia.
Atopic dermatitis is a type of dermatitis that affects the skin.

Yes

No

Do you have a history of using Lidocaine to cure a herpes infection?
If so, how successful were they?
If not, what treatment did you employ to get rid of your previous outbreak?

Yes

No

Do you have a history of using Valaciclovir tablets to cure a herpes infection?
If so, how successful were they?
If not, what treatment did you employ to get rid of your previous outbreak?

Yes

No

Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.

Yes

No

Were there any negative side effects from the treatment?

Yes

No

kindly explain the present symptoms you are experiencing.

Have you noticed a change in your symptoms since you got infected and consulted your doctor?
Do you require assistance?

Yes

No

Prior to the outbreak, were you used to getting a tingling or burning feeling in the affected area?

Yes

No

Since your last infection, have the lesions expanded to a new location?
If so, could you kindly specify where the new lesions have appeared?

Yes

No

In the last one year, how many times have you suffered the infection?
Kindly select your option

Never

Once or twice

At most four times

At most six times

More than seven times

Do you mind providing a clear image of your condition?
In the event whereby a certified medical practitioner has not examined you with warts, failure to provide a picture of your condition might lead to your treatment being delayed.
Please provide clear and Close-ups images of the affected area so that our specialists can accurately assess your issue.
This question is not mandatory

Do you suffer the following conditions?
Thrush
Weight reduction that occurs unintentionally
Pain in the chest
Urine with blood
Urinary discomfort
Stools with blood in them
Infections of the urinary tract (UTI)
Sweats at night
Fever
Do you require assistance?

Yes

No

Have you been diagnosed with HIV or having a weakened immunity?
Do you require assistance?

Yes

No

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

No

Do you have a history of using Aciclovir tablets to cure a herpes infection?
If so, how successful were they?
If not, what treatment did you employ to get rid of your previous outbreak?

Yes

No

Do you have a history of using Valtrex tablets to cure a herpes infection?
If so, how successful were they?
If not, what treatment did you employ to get rid of your previous outbreak?

Yes

No

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Genital Herpes

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