About Your Health
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Has a certified medical practitioner examined you with genital herpes?
If you answered no, please explain how you discovered you have genital herpes.
Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Date of Birth
Use the calendar to select your date of birth.
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Can you relate to the following?
You have an underlying medical condition
Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.
Do you have a history of using Instillagel tablets to cure a herpes infection?
If so, how successful were they?
Are you experiencing any of the following problems?
Anaemia.
Do you have a history of using Lidocaine to cure a herpes infection?
If so, how successful were they?
Do you have a history of using Valaciclovir tablets to cure a herpes infection?
If so, how successful were they?
Are you on any of the following medication?
Antibiotics.
Were there any negative side effects from the treatment?
kindly explain the present symptoms you are experiencing.
Have you noticed a change in your symptoms since you got infected and consulted your doctor?
Do you require assistance?
Prior to the outbreak, were you used to getting a tingling or burning feeling in the affected area?
Since your last infection, have the lesions expanded to a new location?
If so, could you kindly specify where the new lesions have appeared?
In the last one year, how many times have you suffered the infection?
Kindly select your option
Do you mind providing a clear image of your condition?
In the event whereby a certified medical practitioner has not examined you with warts, failure to provide a picture of your condition might lead to your treatment being delayed.
Do you suffer the following conditions?
Thrush
Have you been diagnosed with HIV or having a weakened immunity?
Do you require assistance?
Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
Do you have a history of using Aciclovir tablets to cure a herpes infection?
If so, how successful were they?
Do you have a history of using Valtrex tablets to cure a herpes infection?
If so, how successful were they?
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