Suspected UTI Form

Patient Name:

Patient Date of Birth:

Patient Address, Telephone Number and Email:

Symptoms (Please tick all those that apply):

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

Further Information