UTI Assessment

Please complete this form if requested for a possible urinary tract infection.

To ensure that your request is dealt with in an acceptable timeframe, please ONLY complete and submit this form during Practice opening times.

UTI Assessment


Do you have pain passing urine?
Is your urine cloudy?
Are you passing urine more at nighttime?
Please give as much detail as possible.

Please answer if you have had any of the following symptoms that are severe and new in nature:
Do you have to rush to the toilet to pass urine?
Have you seen any blood in your urine?
Are you passing urine much more often than normal?
Do you have any pain and tenderness (pain on pressing) in your lower tummy?

If Applicable

Could you be pregnant?
Do you have any new or unusual vaginal discharge?
Have you had unprotected sexual intercourse with a new partner in the last year?
Have you been treated for a recent urine infection?