名字 Name

邮箱 Email *

联系电话 Phone *

地址 Address

生日 Date Of Birth

职业 Occupation

婚姻状况 Marital Status

未婚 Single

已婚 Married

离异 Divorced

丧偶 Widowed

目前有没有性生活 Are you currently sexually active?

是 Yes

否 No

是否生过孩子？Have you given birth?

是 Yes

否 No

如果有，孩子的年龄（请分别填写) If yes, ages of children (please specify)

月经情况 Menstrual Cycle

正常 Normal

异常 Abnormal（颜色 Color、气味 Odor）等etc

是否有私密区域瘙痒、异味或不适问题？Do you experience any itching, odor, or discomfort in your intimate area?

是 Yes

否 No

是否曾经有同房出血或不明原因阴道出血的问题？Have you ever experienced bleeding during sexual intercourse or any unexplained vaginal bleeding?

是 Yes

否 No

是否曾经接受过其他私密护理项目？ Have you previously undergone any other intimate care treatments?

是 Yes

否 No

希望改善的私密护理需求（可多选）Intimate concerns you would like to improve (select all that apply)

最后一次妇科检查时间 Last Gynecological examination date

是否有其他妇科相关问题或状况？（可多选） Do you have any other gynecological concerns or conditions? (Select all that apply)