Name *

First Name

Last Name

Did your GP or 111 refer you to us?

Yes

No

Not sure

I understand that the pharmacist may need to access my summary care record and I consent to this *

Yes

No

I understand that my GP will receive a summary of my consultation if appropriate *

Yes

No

Please tick if you:

are aged 15 or under, 65 or over

are pregnant or there could be a chance you are

have a urinary catheter

have had 2 or more UTI's in the last 6 months

have had 3 or more UTI's in the last 12 months

have pain in your back under your ribs

Have nausea or vomitting

have flu like symptoms

have shaking chills or temperature about 37.9 degrees

Please tick if you:

have abnormal vaginal discharge

are immunosuppressed

experiencing vaginal symptoms of menopause

recently had a new sexual partner or change to your sexual habits

Please tick if you have any of the following symptoms:

burning pain when passing urine

needing to pass urine in the night

cloudy urine

urgent need to urinate

need to urinate more than usual

blood visible in urine

pain or tenderness in lower abdomen