Urinary Microbiome Patterns

1

Name* This field is required.

First Name

Last Name

2

Please list out all allergies (foods, herbs, drugs)* This field is required.

3

Please Describe Your Predominant Urine Color Currently* This field is required.

Dark Concentrated

Pale

Cloudy

Pink/Red/Purple

Other

4

Please Describe Your Urinary Pain* This field is required.

Burning

Stabbing/Localised

"Mild Dragging" Empty Discomfort (Typically After Urination)

Other

5

Please Describe Your Urinary Frequency* This field is required.

Frequent, Urgent and Concentrated

Frequent and Pale

Frequent and Pale with a Weak or Broken Stream

Other

6

Please Describe Timing of Your Urinary Pain* This field is required.

Pain During Urination

Pain Before Urination

Pain After Urination

Other

7

Do you have a history of stones?* This field is required.

I currently have stones

I have had stones in the past

I have never had stones

Other

8

Is there anything else we should know regarding your urination?* This field is required.

9

Please upload an image of the top of your tongue

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10

Please upload an image of the underside of your tongue

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