Pharmacy First UTI Questionnaire NHS Pharmacy First - Uncomplicated UTI Pre-Consultation QuestionnaireStep 1Step 2Step 3Step 4Step 5NHS Pharmacy First ServiceUncomplicated Lower Urinary Tract Infection (UTI) Pre-Consultation Questionnaire for Women Aged 16 to 64 inclusive.Please note: A pharmacist assessment is required. Antibiotic treatment is clinical-decision dependent and is not guaranteed.PreviousNextAre you a female aged between 16 and 64 years inclusive? Yes No (You are not eligible for this specific Pharmacy First service path)Do you have any of the following urgent symptoms (Red Flags)? Fever or rigors (shivering/chills) Flank pain or kidney pain (pain in your back/side) Vomiting Severe illness or feeling generally very unwell New confusion or altered mental state Visible blood in your urine with blood clots Pregnancy or possible pregnancy None of the abovePreviousNextFirst NameLast NameDate of BirthContact Phone NumberEmail AddressFull AddressAddress Line 1Address Line 2Town / CityStatePostcodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweNHS Number (Optional)PreviousNextWhich of the following symptoms are you currently experiencing? Dysuria (pain or burning sensation when passing urine) New nocturia (needing to pass urine more than once overnight) Cloudy urine (visible cloudiness to the naked eye) Frequency (needing to pass urine more often than usual) Urgency (a sudden, pressing need to pass urine) Haematuria (visible blood in urine without clots) Vaginal discharge or vaginal irritation None of the aboveHow long have you had these symptoms?- Select Duration -Less than 24 hours1 to 3 daysMore than 3 daysHave you had a diagnosed UTI in the past 6 months, or 3 or more UTIs in the past 12 months? Yes NoHave you taken any antibiotics in the last 28 days? Yes NoPreviousNextDo any of the following apply to you? Currently breastfeeding Kidney disease or renal impairment Immune suppression (e.g., chemotherapy, HIV, immunosuppressive medicines) Diabetes None of the aboveCurrent MedicinesAllergiesRecent Treatments TriedPreferred Consultation Date & Time I consent to the pharmacist assessing my symptoms. I understand that completing this form does not guarantee that antibiotics will be prescribed, and that a clinical assessment is necessary to determine the safest course of treatment. Previous Submit Form
