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Geneveve Questionnaire

We realize that the seemingly small issues can have a profound impact on your overall quality of life and we are committed to offering specialized services that help our patients feel their very best. WE have recently added a new procedure, Geneveve, which treats a very common condition called vaginal laxity. A natural outcome of aging, genetics, lifestyle or vaginal childbirth. We realize that many women may be adversely impacted by this and we would like to give you the opportunity to determine if Geneveve is right for you. We recognize patients can be hesitant to bring up personal or intimate issues but want to assure you we welcome your questions and are available to discuss this further with you.

Privacy is taken seriously at Woman Essence. We do NOT share your information with third parties.

HAVE YOU EVER EXPERIENCED THE FOLLOWING?

1.(a) Urine leakage especially when coughing, sneezing, jumping, etc. (required)
YesNo

1.(b) If you answered yes to 1(a) how many times daily?

2. Disrupted sleep due to frequent trips to the bathroom (required)
YesNo

3. Reduced sensation during intercourse (required)
YesNo

4. Feeling of laxity during intercourse (required)
YesNo

5. Feeling that the vaginal area is not as firm or tight as it once was (required)
YesNo

6. A general sense of laxity in the vaginal area (required)
YesNo

7. Tampons sliding (required)
YesNo

HOW WOULD YOU RATE YOUR CURRENT LEVEL OF VAGINAL LAXITY?

1. Choose One (required)
LooseModerately LooseSlightly LooseNeither Loose nor TightSlightly TightModerately TightTight

2. Has this changed over time? (required)
YesNo

HAS A FEELING OF LAXITY AFFECTED YOUR:

1. Self-confidence (required)
YesNo

2. Sexual self-image (required)
YesNo

3. Interest in having sex (required)
YesNo

4. Overall sexual enjoyment (required)
YesNo

5. Other (please explain):

DO YOU THINK SOME DEGREE OF LAXITY HAS AFFECTED YOUR PARTNER"S EXPERIENCE? (required)
YesNo

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