UTI (Urinary Tract Infection)

Have you ever previously been diagnosed with cystitis or a urinary tract infection by a GP or other healthcare professional?

Are you currently experiencing symptoms of a Urinary tract infection?

Have you had a previous episode of a urinary traction infection in the last 4 weeks?

In the last 12 months have you experienced a urinary tract infection on more than 3 separate occasions?

Have you ever previously had a urinary tract infection which has not been treated successfully by the first course of antibiotics you received?

Have you ever been previously informed that your urinary tract infection is resistant to an antibiotic?

Are you currently experiencing any of the following symptoms
- Blood in your stools or urine
- Unintentional weight loss
- Night sweats
- Fever
- Pain when passing urine
- Genital discharge

Have you ever previously been informed that you have any form of Kidney disease or reduced kidney function?

Have you ever previously been diagnosed with any other medical conditions?

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Is there any other information you would like to share with our prescribing team?

We strongly recommend that you inform your GP of any treatment you receive. Would you like Bramley Pharmacy to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 65
- This treatment is for my use only
- I have the capacity to make decisions about my own healthcare
- I have understood all the questions and have answered this consultation truthfully and completely
- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health
- I will read the patient information leaflet supplied with this medication
- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health
- I have read, understood and agree with our Terms and Conditions