Urinary Tract Infections (UTIs)

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Urinary Tract Infection (UTI)

Urinary Tract Infection (UTI) is an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra.

For more information on UTIs, visit: Urinary tract infections (UTIs) - NHS (www.nhs.uk)

PLEASE NOTE: We DO NOT accept submission forms for UTIs if they have been filled in over the weekend (After 5pm on a Friday, a Saturday, or before 5pm on a Sunday). Any that have been filled in will be rejected when we re-open on a Monday. Please only fill this form in on a weekday, or after 5pm on a Sunday. If you feel you have an UTI during the weekend, please contact 111.

Please do not call the surgery regarding an antibiotic prescription relating to your UTI problem. We will contact you with any further action needed, including any prescriptions that may have been issued, when your form is reviewed and completed.

Are you filling this form in on a Weekend (after 5pm on a Friday, on a Saturday, or before 5pm on a Sunday)?: *

As stated above, we do NOT accept UTI submission forms that have been filled in after 5pm on a Friday night, or on a weekend (Saturday, or a Sunday before 5pm). Your form WILL BE REJECTED if you fill this in inappropriately.

If you feel you have a UTI on a weekend day then please contact 111.

Are you any of the following:

Are you Male?: *

Are you under the age of 18?: *

Are you a kidney transplant patient?: *

Do you have a catheter?: *

Are you currently pregnant?: *

As you have selected 'YES' on one of the above questions, please:

Continue to fill in this form and submit it to us - we still need to know your symptoms

and also -

Please drop off a urine sample at our Victoria House Surgery

This is only valid if you have selected YES on one of the above questions - if you have incorrectly selected YES on a question, it is likely that your form will be rejected and we will not be able to accept your urine sample.

Please continue to fill in this form.

Please answer the following questions:

Are you breastfeeding?: *

Have you given birth less than 12 weeks ago?: *

Have you had 2 or more UTI's in the past 6 months?: *

Have you had 3 or more UTI's in the past 12 months?: *

Have you not passed ANY urine in the last 12 hours?: *

You have ticked the box to say you have NOT passed any urine in the last 12 hours.

As you have ticked this box, we advise all patients who have not passed any urine in the last 12 hours to attend A&E. We are unable to offer our patients any further support regarding their suspected UTI if this is the case.

Please do NOT submit this form - it will be rejected if you do so.

Symptoms

Please tick yes or no for the following symptoms

Do you:

Have pain in lower stomach?: *

Have kidney or side pain?: *

Have a temperature?: *

Are you feeling hot or cold?: *

Are you vomiting?: *

Have blood in the urine?: *

Have a burning or stinging sensation?: *

Are you passing urine more at night?: *

Have a urgent need to pee?: *

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Urinary Tract Infections (UTIs)

Urinary Tract Infection (UTI)

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