Urinary Tract Infection (UTI) Assessment

Please complete this form if you think you may have a urinary tract infection (UTI).

Urinary Tract Infection Assessment

Section

Gender: *
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?
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 13:00 - 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.

*