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Kingsway Surgery

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Braunstone Life Article Archive

NEW Online Consultations
Covid 19
Appointments
Prescriptions
New Patients
Services
Patient Record
Change of Details form
Online Forms
Health Advice
Social Prescribing
Braunstone Life Article Archive

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Suspected UTI Form

Suspected UTI Form

Suspected UTI Form

Please complete this form for suspected urinary tract infection. Please only provide a urine sample if your GP has asked you to.

Suspected UTI Form

Please complete this form for suspected urinary tract infection. Please only provide a urine sample if your GP has asked you to.

Patient Name:

Patient Date of Birth:

Patient Address, Telephone Number and Email:

Symptoms (Please tick all those that apply):

Pain on Passing Urine

Urgency when Passing Urine

Increased Frequency of Passing Urine

Blood in Urine

Dark Coloured Urine

Itching

Soreness when NOT Passing Urine

Discharge from Vagina or Penis

Back Pain

Lower Abdominal Pain

Upper Abdominal Pain

Temperature Symptoms

Other (please state below)

Other Symptoms:

How many days have you had your symptoms?

Have you had any antibiotics for a UTI in the last 4 weeks?

Yes

No

How many times have you been prescribed antibiotics in the last 12 months?

Are you currently pregnant or breastfeeding?

Yes

No

Do you have any known allergies?

Yes

No

If yes, please state below:

Do you have a urinary catheter?

Yes

No

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Page last reviewed: 22 April 2022
Page created: 06 August 2021

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