Urinary Tract Infection Patient Information
Today's Date:
Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Gender
Email
example@example.com
Phone
Address
Address
Street Address Line 2
City
State
Zip
Primary Care Provider
Primary Care Phone
1. Are you older than 18 but younger than 65 years old?
Yes
No
2. Do you have a history of urinary tract infections?
Yes
No
If yes, please explain how many over what time period
3. Do you have one or more of the following symptoms? (Select all that apply)
Painful urination
Increased frequency of urination
Increased urgency of urination
4. Do you have any of the following additional symptoms?
Vaginal discharge or itching
Nausea/vomiting
Flank pain
Other:
Other: please explain
5. Are you pregnant or breastfeeding?
Yes
No
6. Are you post-menopausal?
Yes
No
7. Are you diabetic?
Yes
No
8. Have you ever been diagnosed with a weakened immune system? (e.g., cancer, HIV/AIDS, transplant, long term steroids, etc.)?
Yes
No
If yes, please explain
9. Have you ever been diagnosed with C. diff (Clostridioides difficile)?
Yes
No
10. Do you have a history of kidney transplant, urologic surgery (ureteral implantation, cystectomy, urinary diversion), or abnormal urinary tract function or structure (indwelling catheter, chronic intermittent catheterization, neurogenic bladder, kidney stones, or kidney stents)?
Yes
No
11. Do you have a history of allergic reactions to antibiotics, such as Pencillin, Amoxicillin, Cephalexin, Clarithromycin, or Clindamycin?
Yes
No
If yes, please explain what happened
Do you have any other medication allergies? If yes, please explain
12. Do you have any pending test for your symptoms at another location?
Yes
No
13. Have you had an inpatient or hospital stay in the previous 30 days?
Yes
No
14. Have you been prescribed antibiotics in the previous 30 days?
Yes
No
If yes, please explain what antibiotic and what for
15. When did your symptoms start?
Within the last day
1-3 days ago
4-6 days ago
Greater than 7 days ago
If you are male or have vaginal symptoms if female, younger than 18 or older than 65, answered "Yes" to any question 5-13, have never had a UTI or have had greater than 3 UTI per year, and/or have had symptoms longer than 7 days, you are not eligible for testing at our pharmacies. Please schedule an appointment with your Primary Care Provider or local Urgent Care clinic for further treatment.
I agree that I have read the above statement and have answered all questions truthfully and to the best of my knowledge.
16. Please list any current medications (prescription, OTC, topical, pain or allergy, supplements, vitamins, etc.)
17. What treatments have you tried for your current concern, if any?
After signing and submitting this form, I will call the selected pharmacy below to schedule my appointment.
I agree to call Andover Drug at (316) 260-6030
I agree to call Damm Pharmacy at (316) 788-5533
I agree to call Graves Drug - Winfield at (620) 221-0080
I agree to call Graves Drug - Ark City at (620) 442-2300
How did you hear about this service?
Signature
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