Raf

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symtoms

Are you currently suffering with symptoms of a urine infection (UTI)?

Yes No

Please select the symptoms that you are currently experiencing.

Please select ALL that apply.
Select one or more answers:

Burning or stinging when you pee
Dark or cloudy urine
Strong smelling urine
Waking in the night to urinate
Needing to pee often and urgently
Unusual vaginal discharge
Pain or inflammation of the vagina

Have you seen any blood in your urine?

Yes No

Have you had the symptoms for more than 7 days?

Yes No

How many cases of urine infections have you had in the last year?

Select the most appropriate answer:

Zero
One
Two
Three
Four or more

Health

Are you receiving vaccination with the oral typhoid vaccine (Vivotif) or have you completed vaccination in the last 10 days?

Yes No

Are you currently using a catheter to drain your urine?

Yes No

Have you ever had any operation in your kidneys or bladder?

Yes No

Do you have Diabetes?

Yes No

Do you have any allergies?

Yes No

Are you currently pregnant or breastfeeding?

Yes No

Are you experiencing a fever/high temperature?

Yes No

Are you aware you should seek urgent medical advice if you experience back pain or flu-like symptoms?

Yes No

Are you experiencing nausea and vomiting?

Yes No

Do you take any of the following medicines?

Amiodarone (for irregular heart rhythms).
Antibiotics (such as rifampicin).
Anticoagulants (to prevent your blood clotting such as warfarin).
Ciclosporin (to prevent rejection after transplantation).
Digoxin (to treat heart conditions).
Phenytoin (to treat epilepsy).
Pyrimethamine (to treat malaria).
Bone marrow depressants.
Methotrexate

Yes No

Medication

Have you been treated using an antibiotic during the past 7 days?

Yes No

Are you currently using regular contraception?

No
Yes, I use a combined pill/patch
Yes, I use a mini pill/implant/injection or coil

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Agreement

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Medical Assesment Urine Infection