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Male Female Other

    1 - Which of the following symptoms are you currently experiencing?*

  • Itching
    Burning
    Dryness
    Painful intercourse
    Other

    • 2 - Have you tried any vaginal product for yeast infections in the last 3 months?*

  • Yes
    No

    • 3 - Was your past treatment effective?


    • Please also list the medication names and how long you used them (or if you are still using them). If you haven't tried any treatments, you can leave this question blank.

    4 - Have you taken steroids orally, by injection or inhalation?*

  • Yes, for more than 2 weeks
    Yes, for less than 2 weeks
    No
    • Radio Group

    5 - Do you experience vaginal itching or burning? *

  • Yes
    No
    • Radio Group

    6 - Have you experience any vaginal discharge recently? If so, what color would best describe it? *

  • White
    Yellow-green
    Gray
    Red
    Pink
    Clear
    I haven't had any vaginal discharge recently
    • Radio Group

    7 - Do you have frequent urinary tract infections, bacterial infections or yeast infections?*

  • Yes
    No

    • 8 - Have you been diagnosed with diabetes?*

  • Yes
    No

    • 9 - Have you taken antibiotics in the last month? *

  • Yes
    No

    • 10 - Have you taken birth control pills in the last month? *

  • Yes
    No

    • 11 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


    • 12 - Do you take any medicines, vitamins, or supplements?


    • Please list them here.

    13 - Please list any allergies you have.


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    14 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?


    • 15 - Do you have a preference on medication type? *

  • No preference
    Oral treatment
    Topical cream
    Vaginal suppository

    • 16 - Do you have a preferred treatment?*

  • No preference
    Miconazole vaginal cream|(Generic Monistat®)
    Miconazole vaginal suppository|(Generic Monistat®)
    Miconazole combo kit||(Generic Monistat®)
    Fluconazole|(Generic Diflucan®)
    • Don't worry if you're not sure. Your doctor will help you pick the best one for you.

    17 - Do you have a preferred dose or strength?


    • 18 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
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