Herpes, genital

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Herpes, genital

Texas Telemedicine Doctor

Use this form if you have been diagnosed with genital herpes in the past. If you have never been diagnosed with genital herpes but are concerned you may have it, please use the STD form.

Last name *

Date of birth *

YYYY

When was the last time you had a genital herpes outbreak?

More than a 1 year ago

6 months to 1 year

Within the last 6 months

I currently have an outbreak

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How often do you get an outbreak?

More than 6 times a year

3 - 6 times a year

1 - 2 times a year

Less than once a year

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How do you take your herpes medication?

I only take my medication when outbreaks occur

I take daily suppressive therapy

I treat outbreaks when they occur and I take daily suppressive therapy

I only take my medication when outbreaks occur, but I am interested in daily suppressive therapy

I don't currently take any medication for herpes

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Have you been compliant in taking your medication(s)?

Yes, I always take my medication

Mostly, I sometimes miss a dose but not very often

I forget to take my medication 2 or more times a week

I am not currently taking my medication

I have not been prescribed medication

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Medication side effects - If you are experiencing any symptoms that you think are related to your herpes medication, please tell me about them. If you are not, enter "None."

Example: I think acyclovir gives me a headache

Do you feel like your current medication regimen controls your herpes?

Yes, my symptoms are controlled

I feel like my control could be better

My symptoms are not controlled

Other:

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Is there anything else about your herpes that you would like me to know?

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