Urine Infection Questionnaire

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Are you pregnant or possibly pregnant?

Yes

Is your stomach swollen?

Yes

Are you shivering uncontrollably?

Yes

Do you have visible blood in your urine?

Yes

Do you have pain in your stomach, lower back or side?

Yes

Has urinating become painful?

Yes

Do you have to urinate more often than usual?

Yes

Do you feel hot?

Yes

Do you feel you still need to urinate, even after you’ve been to the toilet?

Yes

Do you feel you need to urinate all the time?

Yes

Do you feel you need to urinate all the time?

Yes

Does your urine smell different from usual?

Yes

Have you had urine infections in the past?

Yes

Your temperature

Your pulse or heart rate

Your blood pressure

Your oxygen level

A brief description of your symptoms, when they started, how they have changed and what treatments you have already tried.

0 of 100 max words

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This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Urine Infection Questionnaire

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