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Please complete the following questions and click the “Next” button below.

What subtype of vulvodynia have you been diagnosed with?

Generalized Vulvodynia

Vulvar Vestibulitis Syndrome / Vestibulodynia
(pain in the vestibule due to touch or applied pressure)

Both

Something else; please specify:

I don’t know

 

How long ago were you first diagnosed with generalized vulvodynia or vulvar vestibulitis?

months ago

 

When did you first start experiencing vulvodynia symptoms?

months ago

 

How many providers did you visit before being diagnosed with vulvodynia?

 

Did you ever experience excessive pain on contact to your genital area? For example, upon insertion of a tampon, at the time of sexual intercourse, or during a pelvic examination?

Yes
No
Not Sure

 

Did you ever experience burning in your genital area that persisted for 3 months or longer?

Yes
No
Not Sure

 

If you answered yes to the previous two questions, since your first episode, how many episodes have you had?

Less than 10 episodes
10-20 episodes
21-30 episodes
More than 30 episodes

 

Did this problem ever limit or prevent you from having intercourse?

Yes
No
Not Sure

 

The following questions are asked only to ensure that we survey a diverse group of women:
   

What is your age? 

years
   

What state do you live in? 
   

What is your marital status?

Married

Single

Divorced

Partner

Engaged

Separated

Other; please specify:

   

Please select the highest level of education you’ve completed:

Did not complete high school

High school or GED

Associate Degree

Undergraduate Degree

Graduate Degree

Post-graduate Degree (MD, JD, etc.)

Other; please specify:

   

What is your household income?   (Please include all sources of yearly income such as wages, tips, investment income, self-employment income, alimony, child support, etc.)

$20,000/year or less

$20,000-$49,000

$50,000-$69,000

$70,000-$99,000

$100,000-$129,000

$130,000-$149,000

$150,000 or more
   

Do you have medical insurance?

No
Yes
 
   

What is your ethnicity? (check all that apply)

Caucasian / non-Hispanic

African American / non-Hispanic

Hispanic

Asian / Pacific Islander

Other; please specify:

   

Have you been diagnosed by a medical professional with any of the following medical conditions?  (please check all that apply) 

Interstitial Cystitis

Fibromyalgia

Chronic Fatigue Syndrome

Irritable Bowel Syndrome

Endometriosis

TMJ Syndrome

Migraine Headache

Burning Mouth Syndrome

   

Do you suffer from any other chronic illnesses?

No

Yes; please list all chronic illnesses that you suffer from:
 

 

Please create a username and password for future logins:

Username (email address):

Password (city where you were born):

 

The National Vulvodynia Association is a nonprofit organization that strives to improve women's lives through education, support, advocacy and research funding. The NVA is not a medical authority and strongly recommends that you consult your own health care provider regarding any course of treatment or medication.

Last Updated on February 2, 2012