National Vulvodynia Association

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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:

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The National Vulvodynia Association (NVA) is an educational, nonprofit organization founded to disseminate information on vulvodynia. The NVA recommends that you consult your own health care practitioner to determine which course of treatment or medication is appropriate for you.

Last Updated on July 7, 2010