Personal History–

First Name
Middle Name
Last Name
Age	Yrs.
Marital Status	Married Unmarried Divorce Widow
Height (in Inches)		Weight	KG/Ponds
Education Qualifications	Under-Graduate Graduate Post Graduate Professional Others	Occupation
Address
City		Country
State		Phone ( Wih STD Code)
Zip /Pin Code		Email
History of Any Sexual Abuse :
History of Alcohol/Smoking /DrugAbuse :

Medical History– Have you suffered from any of the following in the past :

Asthma :	Yes No	Cardiac Problem :	Yes No
Neurological Disorder :	Yes No	Depression :	Yes No
Anxiety :	Yes No	Urinary Infection :	Yes No
Hypertension :	Yes No	History of any operation :	Yes No
Any Injury to Genital Area :		Yes No
Suicidal Ideas / Attempts :
Menstrual History :
Frequency of Menstruation :(No. of days between 2 cycles) No. of days of bleeding : Any History of Leukorrhoea (white discharge), Gonorrhoea, Herpes, Syphilis or any other Sexually Transmitted Diseases :
Any Treatment for Vaginismus in the past

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Sexual History :–

Sexual Desire :		Yes NO
Lubrication in vagina upon arousal :		Frequently Occassionally Scanty Never
Orgasm / Climax :		Frequently Rarely Never Don't Know
Your Views on Sex Relationship / Intercourse :
What according to you is the cause of this problem (Your own views) :

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