Herpes Survey

Survey

View the experiences of others here.

Take our Survey

Let your voice be heard!
Submit the survey and include YOUR experiences
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    Your Name (required)

    Your Email (required)

    Subject

    [your-subject]

    Gender
    MaleFemale

    Age

    Marital Status
    MarriedSingle

    Number of Sexual Partners

    Transmission Prevention
    CondomsFoamsAbstinenceNone

    At what Age did you contract Herpes?

    Are you a Herpes carrier?
    YesNo

    What type of Herpes do you have?
    Type 1Type 2

    What diagnostic test was used to determine the type of Herpes?
    Living Cell Culture(PAP) smearOtherNone

    Do you have any of the following herpes symptoms during lesion formation?
    sharp painsmuscle achesswollen lymph glandsheadachesfever and general malaise

    What treatments do you use for Herpes?
    Prescription medicationOver-the-counter medicationPsychotherapyDiet/NutritionVitamins/HerbsStress ReductionNone

    How frequently do you have outbreak recurrences?
    1 time per 1-5 years4-7 times per year1-2 times per month

    Average duration of Herpes recurrences
    1-3 days4-7 days8-10 daysmore than 10 days

    What do you feel causes your herpes outbreaks?
    Stress at homeStress at workSunburnOther health problemsPoor nutritionVigorous sexual intercourseMenstrual cycleOver-tirednessDon't know causes

    How has herpes affected your pregnancy plans?
    0 (Not at all)1234 (A great deal)

    Highest education level
    Grade schoolSome high schoolHigh school graduateSome collegeCollege graduateSome graduate schoolGraduate degreeProfessional degree

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

    Regional Information:

    City

    State/Province

    Country

    Thank you for your participation.

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