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Gender

Male Female

Age



Marital status

Married Single

Number of sexual partners



Transmission prevention

Condoms
Foams
Abstinence
None

At what age did you contract herpes?



Are you a carrier?

Yes No

What type of herpes do you have?

Type 1 Type 2

What diagnostic test was used to determine the type?

Living Cell Culture
(PAP) smear
Other
None

Do you have any of the following during lesion formation?

sharp pains
muscle aches
swollen lymph glands
headaches
fever and general malaise

Treatment

Prescription medication
Over-the-counter medication
Psychotherapy
Diet/Nutrition
Vitamins/Herbs
Stress Reduction
None

Frequency of outbreak recurrences

1 time from 1-5 years
4-7 times per year
1-2 times per month

Average duration of recurrences

1-3 days
4-7 days
8-10 days
more than 10 days

What do you feel causes your herpes outbreaks?

Stress at home
Stress at work
Sunburn
Other health problems
Poor nutrition
Vigorous sexual intercourse
Menstrual cycle
Over-tiredness
Don't know causes

How has herpes affected your pregnancy plans?

0 (Not at all)
1
2
3
4 (A great deal)

Highest education level

Grade school
Some high school
High school graduate
Some college
College Graduate
Some graduate School
Graduate degree
Professional degree

Do you have a herpes experience you'd like share with others?


Regional information

City:
State/Province:
Country:
Email: (optional)

Where did you hear about this site?

Thank you for your participation.


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