UTI Female

Name

First Name

Last Name

DATE OF BIRTHpatient's DOB

Date

Sex at Birth

example@example.com

Phone Number

Please enter a valid phone number.

Select from the following symptoms you are having* This field is required.SELECT ALL THAT APPLY

Painful Urination

Low backache

Urinary Frequency

Low abdominal ache (Mild)

Dark urine

Foul smelling urine

Vaginal Discharge

Vaginal Itching

Vaginal Rash

Slow Urine Stream

Are you having blood in your urine that is not related to your menstruation?* This field is required.

YESNO

How much blood is in your urine?* This field is required.

Very slight tinge of blood

Type option 2

Clots and excessive bleeding

Type option 4

Are you having severe pain?* This field is required.

YESNO

List all your medication Allergies or put "none" if you have none* This field is required.

Are you Allergic to any of the following medications?* This field is required.

Amoxicillin (Penicillins)

Cephalexin (Cephalosporins)

Nitrofurantoin (Macrobid)

Bactrim (Sulfa drugs)

Fluconazole

NO ALLERGIES to any of these listed medications

Check off medical conditions you have a history of* This field is required.This is not family history, this is your personal history

Kidney Disease or dysfunction

Kidney Stones

Urinary Tract Infections

Diabetes

Hypertension (history of elevated bood pressure)

Asthma

Hypothyroidism

Hyperthyroidism

Irritable bowel disease (crohn's or ulcerative colitis)

Stroke

Myocardial Infarction (heart attack)

Epilepsy

Anxiety or Depression

ADHD

Cancer

Anemia

AIDS or HIV

Please describe your symptoms, how long they have been going on, medications you have taken already for the current symptoms and any details you would like the provider to know about to better assist your care.* This field is required.

Which medication would you prefer for your urinary tract infection?SELECT ALL THAT APPLY

Nitrofurantoin

Amoxicillin Clauvinate

Cephalexin

Amoxicillin

Sulfamethoxazole/trimethoprim

Ciprofloxacin

Any medication is acceptable by me

Would you also like medications to prevent yeast infection? * This field is required.

YESNO

Would you like a prescription of pyridium (phenazopyridine)to aid in the pain of urinary tract infection. This is not recommended if you have already taken the prescription for 3 days. Also if the provider chooses to treat you to cover your kidney's, then this medication is not recommended.

YESNO

Are you concerned you may have a sexually transmitted disease?

YESNO

Would you like treatment for a sexually transmitted disease?

YESNO

Date of last day of your last period* This field is required.

Date

Is there any chance you may be pregnant (This will alter prescription, as some medications are not safe for pregnancy). * This field is required.

YESNO

Are you breast feeding?* This field is required.

YESNO

List all your food allergies* This field is required.if no food allergies then put "none"

List all your medication and food allergies* This field is required.If no medication allergies then put "none"

List medications and supplements you take daily Type "none" if you take nothing daily

Have you had a prescription for a urinary tract infection with us in the past? If you have had a prescription in the past we recommend having a urinalysis and urine culture to ensure you are on the correct antibiotics.

YESNO

Would you like a urinalysis and urine culture?we highly recommend you have this testing to help identify the source of your infection to tailor the antibiotic treatment based on the microorganisms found in your urine sample. You may opt to have a one time prescription for antibiotics, and future visit will require testing in order to have a prescription sent in to your pharmacy.

YESNO

Which Pharmacy would you like your prescription sent to?

Terms and Conditions* This field is required.

Signature

Please verify that you are human* This field is required.

Which lab would you like to drop a urine sample off? Please note the pricing for your lab test is not include in the price of today's visit.

IF YOU HAVE SEVERE OR OR SEVERE VAGINAL BLEEDING CALL 911 OR GO TO NEAREST EMERGENCY DEPARMTENT IMMEDIATELY. IT IS NOT SAFE TO CONDUCT A MEDICAL EVALUATION ONLINE.