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Please answer the following questions for medical consultation received in the last 28 days for your generalized vulvodynia and/or vulvar vestibulitis syndrome, not for other conditions or for general medical care. 

 

For the medical appointments you’ve had in the last 28 days, please select the type of provider you visited and answer the questions that follow.  (If none, please proceed to the next question):
 

Visit 1:

Type of Provider:


If Other, Please specify:

 

How much did you have to pay up-front at the appointment (co-payment, deductible and/or amount not covered by insurance) for the visit? (If none, enter $0.)

$

 

What was your total out of pocket transportation expense for the visit (metro, bus, taxi, parking)?  (If none, enter $0.)
$

 

Click here if you've had more than one medical visit in the past 28 days.(If you visited the same provider more than one time, please enter information for each visit separately.)

 

Please answer the following questions regarding any lab work or diagnostic tests (x-ray, MRI, CT-Scan, ultrasound, etc.) you’ve had for your vulvodynia in the last 28 days. (If none, please proceed to the next question):

Please list the name(s) of the lab work and/or diagnostic tests:

How many visits in total:

How much did you have to pay up-front at the visit (co-payment, deductible and/or amount not covered by insurance)?   (If none, enter $0.)

$

 

Please answer the following question regarding any surgical procedures performed for your vulvodynia in the past 28 days.  (If none, please proceed to the next question)

How much did you have to pay up-front at the visit (co-payment, deductible and/or amount not covered by insurance)?
(If none, enter $0.)

$

How many days were you hospitalized for the procedure? (If it was an outpatient procedure, please enter 1. If the procedure was done in the doctor’s office, please enter 0.)

 

In the past 28 days have you been hospitalized due to your vulvodynia?

If yes, how many days were you in the hospital?

What was your total out of pocket expense (co-payment, deductible and/or amount not covered by insurance)?
(If none, enter $0.)

$

 

In the past 28 days, how much have you paid out of pocket (insurance co-payment or not covered by insurance) for prescription medications? (If none, enter $0.)

$

 

In the past 28 days, how much have you paid out of pocket for over-the-counter remedies or self-care measures? (If none, enter $0.)  (This can include a variety of items, such as vitamins, supplements, herbal remedies, topical ointments, over-the-counter medications such as Advil or Tylenol, lubricants, heating pads, cold packs, sitz baths, special chairs, seats, donuts or related items, feminine hygiene products such as 100% cotton menstrual pads, etc.)

$

 

In the last 28 days, have you received and paid any invoices for medical care received since enrolling in this survey?

If yes, please desribe what the invoice was for:
(i.e., office visit, lab work, surgical procedure, hospital visit, prescription medication)

Amount Paid:

$

 

Please answer the following questions regarding your inability to work due to your vulvodynia in the last 28 days.  (If none, please enter 0.)

How many days were you unable to work in total?

 

 

Please estimate the amount of lost income you and your employer have incurred due to the following: (If none, please enter $0.)

Sick leave:

Paid by your employer - Income lost $
Unpaid by your employer - Income lost $

 

 

Leave of absence:

Paid by your employer - Income lost $
Unpaid by your employer - Income lost $

 

 

Direct loss of job
(not receiving unemployment benefits)

Income lost $

 

 

Unemployment disability
(Amount you would have made in the last 28 days if you were working at your former place of employment)

Income lost  $

 

In the last 28 days, how many days were you unable to perform household chores due to your vulvodynia? (If none, please enter 0.)

 

In the last 28 days, how many times have you had to abstain from social activities due to your vulvodynia? (If none, please enter 0.)

 

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