HPV (Human Papillomavirus)

Patient Information

Full Name *

Age *

Gender *

HPV Information

When did you notice if it happens for the first time?

Diagnosed by whom? (Dermatologist? Urologist? Gynecologist?)

Was the diagnosis made only by examination? Was a biopsy done?

Was HPV genotyping done? If so, what type was detected?

Have you been treated?

Yes

No

Which treatment was used? (cryosurgery (freezing), electrosurgery (burning), cream (aldara), solution (condylox) etc.)

Treated by whom? (Dermatologist? Urologist? Gynecologist?)

How many sessions were performed in the applications made by the doctor?

Did you recover completely after the treatment?

Yes

No

Was a biopsy performed if you have no complete recovery?

Yes

No

If you have recurrent HPV, when did you have the first diagnosis?

If you have recurrent HPV, how many times did it recur?

How often did it recur in the last 2 yeras?

What are the previous treatments?

Are you vaccinated?

Yes

No

At what age were you vaccinated? Have you completed all doses?

Were you vaccinated before your sex life started?

Yes

No

Have you been vaccinated before getting HPV?

Yes

No

Is your partner vaccinated?

Yes

No

Has your partner been examined and got the diagnosis of HPV?

Do you have a multi-partner sex life?

Yes

No

Have you had a homosexual relationship?

Yes

No

Do you use condom? (for male patients)

Yes

No

Have you caught any of the other sexually transmitted diseases?

Do you have periodic smear test? (for female patients)

Yes

No

Do you smoke?

Yes

No

Have you been diagnosed with a cancer involving the genital area (anal cancer, cervical-vulvar cancer for female patients, penile cancer for male patients) or a cancer involving the head and neck region?

Yes

No

Do you have any other diseases?

Do you use any medication regularly?

Have you used immunosuppressant drugs in the past?

Yes

No

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

HPV (Human Papillomavirus)