Amber Wellness Group 1944 NE 45th Ave Portland, OR 97213 Phone: 971.319.0045 Fax: 503.296.5712 Mona Lisa Touch Complementary Consult Intake Name(Required) DOB(Required) MM slash DD slash YYYY Address(Required)City(Required) State(Required) Zip(Required) Phone(Required)Email(Required) What is your main reason for seeking this therapy? Do you experience any of the following: Sexual discomfort Vaginal dryness Urinary incontinence Vaginal tears Vaginal itching Vaginal irritation Burning sensation Other concerns: Focused Medical History: Date of last PAP Smear: MM slash DD slash YYYY Results: Current vaginal infection (herpes, yeast, other STD’s):(Required) Yes No History of pelvic organ prolapse:(Required) Yes No Recent or current pregnancy:(Required) Yes No If yes, when? History of reconstructive pelvic surgery with “mesh kits”:(Required) Yes No History of impaired wound healing:(Required) Yes NO History of keloid formation:(Required) Yes No History of radiation to vaginal or colorectal tissue:(Required) Yes No Are you on anticoagulation treatment or have a known thromboembolic condition(Required) Yes No
