Urinalysis Samples

Title *MrsMissMsOther

Email *

Please answer the following questions

Could you be pregnant? *YesNo

When was the 1st day of your last menstrual period? *

Please use format day/month/year e.g. 12/04/2021

Have you got any vaginal discharge or itch? *YesNo

Duration of symptoms? *

Is this your first episode? *YesNo

Have you any pain passing urine? *YesNo

Are you passing urine more frequently? *YesNo

Do you have blood in your urine? *YesNo

Do you have a high temperature? *YesNo

Do you have pain in lower tummy or flank/side? *YesNo

Do you have a catheter? *YesNo

Are you allergic to any Antibiotics? *YesNo

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *I consent to the practice collecting and storing my data from this form.