Urinary Tract Infection Assessment

If you have been advised by the surgery to submit a Urinary Tract Infection Assessment, please use this form.

Urinary Tract Infection Assessment

Urinary Tract Infection Assessment

Which surgery do you normally attend?

Section

Gender: *

Symptoms

Do you have painful urination?
Are you passing urine more frequently?
Do you have lower abdominal pain?
Do you have loin or flank pain?
Is there blood seen in your urine?
Could you be pregnant?
Do you feel unwell?
Are you able to carry out most of your usual activities?
Are you prone to urine infections?

Signs

Is your urine cloudy?
Do you have a temperature?