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Questionnaire for Yeast Infection
Are you a female? Required
Are you currently pregnant? Required
Have you had more than four yeast infections in the last year? Required
Are you between 18 and 65? Required
Have you been diagnosed with a yeast infection in the past? Required
Do you have any of the following systoms? Required
Do you have a thick white orderless discharge? Required
Do you experince any pain when urinating? Required
Are you currently taking any medications? This includes over-the-counter, prescriptions and recreational drugs. Required
Do you have any kown allergies or any adverse reactions to any medication? Required
Have you ever been diagnosed with kidney disease? Required
Have you been advised that you have a prolonged QT interval on a ECG? Required
Do you agree with the folllowing statement below? Required

Please contact us if you experienced any side effects from the treatments. If you start new medication,
or developed any changes in your medical condition, please contact PBJ Medical Rx. 


The treatment is solely for your own use. An information leaflet will be supplied with your medication.

You will notify your primary care physician about your treatment from PBJ Medical Rx


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly. If incorrect information has been received inappropriate clinical decisions can be made and may be harmful to your health.

 

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Thanks. We'll get back to you soon.

PBJ Medical RX

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​VISIT

7380 West Sand Lake Road

Orlando, FL 32819

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​CONTACT US

(800) 485-7962
info@pbjmedicalrx.com

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Medical Discliamer - PBJ Medial Associates LLC

© 2025 PBJ Medical RX. All Rights Reserved

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