The Cornwall Road Medical Practice: Cystitis Questions

Cystitis Questions

Name:
Date:

Please answer the following questions about the symptoms you have at the moment

Are you in any doubt that your current symptoms are due to cystitis?	YES/NO
Are they different from when you have had urine infection in the past?	YES/NO
Are you unwell in yourself (e.g. raised temperature or back pain)?	YES/NO
Do you have any history of kidney problems in the past?	YES/NO
YES/NO
Do you have any long term or current illness? (eg Diabetes)	YES/NO
Is there any blood in the urine (if so, you may need to see the doctor)?	YES/NO
Is there any possibility that you may be pregnant?	YES/NO

If you can answer "No" to all the above questions we can probably give you a prescription for antibiotic treatment quickly without you needing to wait to see a doctor or nurse.

We also need to know:

If so which one/s?

Are you allergic to any antibiotics that you know of?	YES/NO

Are you taking any medication at present?YES/NO

We do ask that you provide a specimen of urine in the special red top container before you take any antibiotic. This will go to the Pathology lab to check the type of infection present and that you have received the best treatment for it. The result comes back to us in 2 working days.

If you would prefer to see a doctor or nurse about your symptoms please make an appointment in the usual way.

Please sign this form when you have read and completed it

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