Urinary Tract Infection/Cystitis Assessment

Name

First

Last

What is your biological sex?

Male
Female

Biological sex is one of the inputs required to determine your eligibility.

2. Have you used this service before?

No, I’m new to this service
Yes, within 3 months
Yes – over 3 months ago

We are going to ask you a few questions about your medical history, to help us decide the most suitable medication for you?

Do you have any allergies?

Do you have any bladder problems?

Have you ever had an allergic or anaphylactic reaction to nitrofurantoin or any other antibiotics?

Do you have any liver or kidney problems?

Do you have any symptoms?

Are you still experiencing symptoms from a previous urinary tract infection?

Are you pregnant, planning pregnancy or is there a possibility you may be pregnant?

Are you currently breast-feeding?

Have you been told by your doctor that you have an intolerance to any sugars (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?

Are you receiving vaccination with the oral typhoid vaccine (Vivotif) or have you completed vaccination in the last 10 days?

Have you EVER experienced the symptoms below with a urinary tract infection (UTI)? Yes No

If yes to the above question, were your symptoms investigated by your GP or other specialist?

If yes, please provide details of the outcome

Are you using an indwelling urinary catheter?

Have you been treated for a urinary tract infection in the last 3 months?

Have you suffered from a UTI in the past 3 months?

Do you suffer from recurring urinary tract infections?

Are you immunosuppressed through disease, treatment or medication?

Do you have blood in your urine?

Are you familiar with the symptoms of an uncomplicated lower urinary tract infection (UTI)?

Are you immunosuppressed through disease, treatment or medication?

Do you have a history of upper urinary tract infection (affecting the kidneys)? Ask your healthcare professional if you are unsure

Have you suffered from more than 3 episodes of UTI in the past 12 months, or more than 2 episodes in the past 6 months?

If yes, was this investigated by your GP or other specialist? If yes, please provide details of the outcome

Do you require a supply of stand by treatment for a urinary tract infection?

If yes, please provide a reason below

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. conditions you have previously been treated for)

Complete Patient Details

What is your age?

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient Consent

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent 2

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)

Patient Name

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction to any acne treatments before?

Do you have any allergies?

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy)

Are you breast feeding?

Have you started puberty?

Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment?

Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea?

Are you currently using any other treatments for acne?

Have you recently received an acne treatment containing antibiotics?

If you have used acne treatments before, did you experience any side effects or skin irritation?

Do you have a history of photo-allergy (skin reactions in the sunlight)?

Do you have, or have you had any of the following? ̵ Regional enteritis (crohn's disease) ̵ Ulcerative colitis (inflamed colon and rectum) ̵ Inflammatory bowel disease or antibiotic-associated colitis (including pseudomembranous colitis)

Have you or any of your close family had skin cancer?

Do you currently have sunburn, broken skin or abraded skin?

Do you have any allergic diseases such as asthma, eczema or rhinitis?

Do you have any liver or kidney problems?

Are you currently using any cosmetics, medicated cleansers or scrubbing solutions?

Do you suffer from severe psychological distress because of your acne?

Have you undergone or recently undergone procedures such as depilation, chemical hair treatments, chemical peels, dermabrasion, laser resurfacing of the skin or phototherapy?

Are you sensitive to sunlight or do you have considerable sun exposure?

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for)

Complete Patient Details

Patients Name

First

Last

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient GP Consent

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent (Other)

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions.

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)

We are going to ask you a few questions about your medical history, to help us decide the most suitable medication for you?

Complete Patient Details

Start Assessment

Complete Patient Details