Urinary Tract Infection (UTI) Assessment

If you have a suspected urinary tract infection or have been asked by the surgery to do so, please submit this form.

Urinary Tract Infection (UTI) Assessment

If you are human, leave this field blank.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Do you have any of the following symptoms?

Discomfort or pain passing urine

Passing urine more frequently at night

Urine that is more cloudy

New discharge from the vagina

New discharge from the penis

Passing urine more frequently during the day

Feeling a sudden urgency to pass urine

Urine has visible blood in it

Feeling more confused

Discomfort or pain in the tummy

New pain in lower back

Nausea

Vomiting

Fever

Shivering

Other symptoms

What other symptoms do you have? *

How long have you had these symptoms? *

Less than 3 days

3 days - 1 week

1 - 2 weeks

More than 2 weeks

What have you done to manage your symptoms?

Painkillers e.g. paracetamol

Antibiotics

Cranberry products

Drinking more fluids

Other remedies

What other remedies have you tried? *

Have you had a urinary tract infection before? *

Yes - in the previous 6 months

Yes - in the previous year

Yes - in the previous 3 years

Yes - more than 3 years ago

No

These are sometimes called a bladder or water infection

Is there a possibility you might be pregnant? *

Yes

No

N/A

Do you have a urinary catheter? *

Yes

No

This is a tube that is inserted into your bladder which is used to empty the bladder and collect urine

*

I confirm that the information provided is accurate to the best of my knowledge