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What is your birth gender?
*
This service is only available for female patients.
Female
Male
Patient’s Details
Name
*
First
Last
DOB
*
Date Format: DD slash MM slash YYYY
NHS
Phone
*
Email
*
Address
*
Street Address
City
Post Code
GP Surgery
*
Please select your GP surgery
Dr Johnson And Partners
Richmond Medical Group - Sheen
Chartfield Surgery
Danebury Avenue Surgery
Essex House
Glebe Road
Kew Medical Practice
Mayfield Surgery
Paradise Road
Parkshot Medical Practice
Putneymead Group Medical Practice
Richmond Medical Group - Kew
Seymour House - Richmond
Seymour House - Ham
The Alton Practice
The Heathbridge Practice
The Roehampton Surgery
The Vineyard Surgery
Other
Please type the name of your GP surgery
Consultation Questions
Do you have any pain, burning or stinging when passing urine?
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Yes
No
Are you needing to pee more than usual, especially at night?
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Yes
No
Do you have cloudy or smelly urine?
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Yes
No
Do you have any other symptoms?
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Like needing to rush to the toilet, blood in your urine or discomfort in your bladder
Yes
No
Which other symptoms do you have
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Needing to rush to the toilet (urgency)
Blood in the urine
Lower abdominal discomfort
None of these symptoms
Have you noticed a change in your vaginal discharge since having these symptoms?
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For example a change in the colour, consistency or odour.
Yes
No
Please describe the discharge you're experiencing:
*
Including any details about the colour, consistency and odour.
When did you notice this change?
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In the last 12 months, have you had any other episodes of cystitis?
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Yes
No
Have you taken antibiotics for cystitis in the last 4 weeks?
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Yes
No
Please provide details
*
Describe which antibiotic you took, and for how long
In the last 12 months, how many times have you had cystitis?
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1 - 2 times
3 or more times
Are your episodes of cystitis related to when you have sex?
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Yes
No
How many of these episodes have been in the last 6 months?
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1 or none
2 or more
Have you discussed the number of times you have cystitis with your GP or doctor?
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Yes
No
Caution
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If you have more than 3 episodes of cystitis in a year, or more than 2 in 6 months, it's important that you discuss this with your GP so they can investigate it further. It's important that they check for any reasons why you may get this number of episodes. Usually this involves checking a urine sample, and may involve other tests.
Have you had a urine sample sent off to the lab by your doctor/nurse?
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Yes
No
Have you had a scan of your kidneys and bladder?
*
Yes
No
Are you breastfeeding, pregnant or is there a chance you could become pregnant during the next month?
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Yes
No
No Applicable
Do you have any existing medical conditions
*
Yes
No
Please provide details
*
Do you have any allergies
*
Yes
No
Please provide details
*
Do you take any medications
*
Yes
No
Please provide details
*
Consent
Consent
*
If you have a fever or uncontrollable shivering, pain in the flank areas of your back or are vomiting, these are signs of a possible severe urine infection that should be checked urgently in person. You should contact your GP or out of hours service immediately, or phone 111 to get advice about your treatment.
I fully understand the questions asked & have answered honestly & truthfully.
I confirm I will read thoroughly the information leaflet provided to understand side-effects of the treatment, their effectiveness and alternative options & am happy to continue with my request.
I confirm & agree that any treatment prescribed for me is for my personal use only.
We will send your name, address and information about your consultation to your GP practice so they can update your health record.
Comments
Dipstick Results
Nitrite
*
Positive
Negative
Leukocyte
*
Positive
Negative
Red Blood Cells (RBC)
*
Positive
Negative
https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/diagnosis/when-to-suspect-uti/ Positive for nitrite or leukocyte and red blood cells (RBC) UTI Negative for nitrite and positive for leukocyte, UTI is equally Negative for all nitrite, leukocyte and RBC, UTI is less likely
Prescription Details
Date of Prescription
*
Date Format: DD slash MM slash YYYY
Medication Prescribed
*
Nitrofurantoin 100mg MR Capsules
Trimethoprim 200mg Tablets
Number of Days of Treatment
*
3 days
7 days
Dose
*
One to be take TWICE daily
Other
Alternative Dose
Any Adverse Effects
N/A
Advice given and any other notes
N/A
Administered by
*
Zaydoun Abbas, 2058373
Shama Mahammed, 2066304
Email
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