Download patient assessment

12/08/2017
Patient assessment for labiaplasty
Please email completed form to [email protected]
How old are you?
Why are you considering labiaplasty?
Cosmetic concerns
Embarrassment
Interference with clothes
Difficulty with sports
Interference with intercourse
Other
What is your motivation?
Personal
Partner
Professional
Other
When did the problem occur?
Since birth
Since puberty
Since childbirth
Other
Childbirth
Have you had any vaginal deliveries?
Have you had caesarean sections?
Are you pregnant at present?
Do you anticipate being pregnant in the future?
Yes
No
Maybe
Do you have any gynaecological problems or sexually transmitted diseases?
No
Is there a family history of genital problems, wound healing problems, scar problems or
bleeding disorders?
No
Do you have any medical problems?
No
Have you had surgery or general anaesthetic and did you have any problems from this?
No surgery
No general anaesthetic
No problems
Other
What medication are you on?
Do you have any medical allergies?
No
How much do you smoke?
Non-smoker
1-10 per day
11-20 per day
20+ per day
Ex-smoker
Other
How much do you drink?
Nothing at all
Rarely
Occasionally
Regularly
Other
What is your job?
Do you do any sports or have any hobbies?
On the pictures below, which most resembles your labia?
Anterior hypertrophy
Central hypertrophy
Diffuse hypertrophy
This section to be filled in by surgeon
Examination
Type of hypertrophy:
Clitoral hooding
STD:
Central
Diffuse
, None
Asymmetry:
Scars:
Anterior
R>L
R<L
None
None
No
Other
Plan
Wedge excision
Rim excision
Chloramphenicol ointment
Jelonet
Gauze
Pads
Ice packs
Information sheet supplied
Clitoral de-hooding / Lignocaine + Adrenaline