Assessment Bladder Infection

1

NameWhat is your full name as on your identification document

First Name

Last Name

2

Your date of birth

Date

3

How old are you?

4

Why do you need a consultation?

I think I have a bladder infection

I have discharge from my vagina

I have discharge from my penis

5

Do you have pain or burning sensation when you urinate?Before or after urinating you feel a sting, burn or pain sensation

YESNO

6

Do you need to urinate more often than usual or small portions each time?You have the urge to urinate and do not feel that you have completely emptied your bladder

YESNO

7

Do you have pain in your lower abdomen or lower to mid back region?

YESNO

8

Do you have a fever?Body temperature of more than 38 degrees celsius or 100.4 degrees Fahrenheit

YESNO

9

Do you feel unwell?You are not feeling your usual self

YESNO

10

Do you have a catheter?A tube inserted into your bladder that drains urine freely into a bag

YESNO

11

Do you have a kidney or bladder disease?A condition (present of past) that affects your kidney and/or bladder for which you are on medication or under specialist care

YESNO

12

Do you have diabetes mellitus?A metabolic disease that causes high blood sugar for which you are on medication or under specialist care

YESNO

13

Do you have an allergy for medication?You developed an immune reaction such as fever, palpitations or difficulty breathing shortly after ingesting a drug or medication

YESNO

14

Which drug are you allergic for?Please specify the name of the drug and the type of reaction you devoped

For example "amoxicilline - anaphylaxis"

15

Do you leak urine from your bladder?Urinary incontinence occurs when you lose control of your bladder without this being your intention.

YESNO

16

Would you like to discuss this with a doctor?Leakage of urine without your control is something that needs a separate consultation.

YESNO

18

Are you menstruating at the moment?You are discharging blood from your uterus as part of a menstrual cycle

YESNO

19

Duration of symptomsIn your own words describe your symptoms. When did your symptoms start? (note limit to 200 characters)

20

Type of symptomsIn your own words describe your symptoms and how it is making you feel at the moment. (note limit to 200 characters)

21

Symptom progressIn your own words describe how your symptoms have evolved. (note limit to 200 characters)

22

Self treatment symptoms.Describe in your own words what if anything you have done to help your condition. (note 200 limit character)

23

Are you pregnant?You have a confirmed pregnancy test or fetus/child growing in your uterus

YESNO

24

Do you have abnormal discharge from your genital region?Abnormal discharge is fluid or mucuous that is yellow, green, white or smells different.

YESNO

25

EmailProvide your email to get a bladder infection assessment score. Based on this socre a doctor will contact you with advice

example@example.com

26

Bladder infection fast-track assessment score

27

Your score reveals that you may currently have a bladder infection based on the answers you provided.

You must contact your own physician or local doctor if you answered yes to the following:

currently pregnant
known kidney or bladder disease
known diabetes mellitus in your medical history
current use of a catheter

We advice that you also fill out the next section to assess your risk of developing a (new) bladder infection.

Once you have completed the form, you will receive an email with the opportunity to choose a consultation with a doctor.

Should you feel you need an urgent consultation please send to welcome@oshclinic.com for further advice.

Please note if your situation is life-threatening you must contact your local emergency service number.

28

Would you like to calculate your probability of a new bladder infection?You can calcuate the probability of another bladder infection. This is an estimate and not intended to be used as a diagnostic tool.

YESNO

29

Number of partnersHow many different sexual partners have you had in the past 12 months?

1

2

More than 3

30

Bowel functionWhat is your bowel function like in a usual month?

Normal

Diarrhoea

Constipation

31

PathogensWhat type of bacterias have (ever) been found in a previous urine culture?

Gram Positive

Gram Negative

32

Hormonal statusIn the past 12 months were you in a fertile state or postmenopausal state?

Fertility

Postmenopausal

33

Number of bladder / urinary infectionsHow many bladder infections have you had in the past 12 months?

Less than 3 times

More than 3 times

34

Antibiotic treatmentHave you previously been treated with antibiotics for a bladder infection without symptoms?

No

Yes

35

Total points

36

Risk of reccurrence bladder infectionThe value provided is in percentage.

37

SignatureBy signing this form you acknowledge that you have truthfully filled out this form. Our team will work hard to get you the best advice within a few hours.

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