Urinary Tract Infection Assessment

If you feel you have a urine infection, please complete the following form. This form will be reviewed by a clinician and we will get in touch with you with any further action.

Requests for samples cannot be accepted after 2pm on Fridays so please refer to a Pharmacy or walk-in centre.

Please do not drop a sample of urine into the Surgery unless we request it. It will not be tested.

Urinary Tract Infection (UTI) Assessment

Section

Sex at birth: *
Are you over 65? *

Symptoms

Do you have painful urination?
Do you have difficulty passing urine?
Are you passing urine more frequently?
Do you need to pass urine more urgently?
Do you have lower abdominal pain?
Do you have loin or flank pain?
Is there blood seen in your urine?
Do you feel unwell?
Are you able to carry out most of your usual activities?
Are you prone to urine infections?
Are you pregnant?
Are you breastfeeding?
Do you have a temperature?
Are you experiencing shivering/chills?
Are you experiencing new or worsening confusion?
Is your urine cloudy?
Are you experiencing new or worsening urinary incontinence?

History

Please select all that apply:

Catheter

Please specify:

Treatments

Urine Sample

Please drop off your urine sample before 12:00 - samples received after this time will be discarded. Sample pots are available from the practice. Please use a clean, sterile container that is clearly labelled with your details.

*