Oak Street Surgery

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Oak Street Surgery

Oak Street, Cwmbran, Gwent, NP44 3LT

01633 866719

Cymraeg

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Suspected Urine Infection Form

Suspected Urine Infection Form

If you suspect you have a urine infection, please comple and submite this form.

You MUST also bring a urine sample to the surgery for testing before 12pm.

If we do not receive your urine sample, this form WILL NOT be processed.

Name

Date of Birth

Age

Your Telephone Number

Symptoms

It is important you select as truthfully as possible so we can provide you with the correct advice and treatment.

Please tick which symptoms you are experiencing:

Burning or stinging on passing urine (Dysuria)

Passing urine more often than usual (Frequency)

Discomfort in the lower abdomen

Needing to rush to the toilet (Urgency)

Passing more urine than normal (Polyuria)

Blood in urine (Hematuria)

Vaginal discharge

Flank pain/ back pain

Fever (Temperature above 38*C)

How long have you had symptoms?

Do you have a Catheter?

Yes

Are you allergic to any antibiotics?

Yes

If yes, which antibiotic?

For Female Patients

Could you be pregnant?

Yes

What was the date of your last period?

Are you breastfeeding?

Yes

If you feel very unwell including severe pain, significant light-headedness or are drowsy then please telephone reception to speak with a clinician.

Thank you. Your message has been sent to your surgery.

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Oak Street Surgery

Oak Street
Cwmbran
Gwent
NP44 3LT

01633 866719

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