• Urinary Tract Infection Risk Assessment Form

  • About You

  • Date of Birth:*
     - -
  • Gender:*

  • About your health

  • Do you have any allergies*
  • Have had 2 or more UTIs in the last 6 months, or 3 or more UTIs in the last 12 months*
  • Are you pregnant or there is a chance you could be pregnant?*
  • Are you breastfeeding?*
  • Do you have a urinary catheter*
  • Do you have any vaginal discharge?*
  • Do you have nausea and, or vomiting?*
  • Do you have new flu like illness?*
  • Do you have any shaking chills or a temperature of 37.9°C or more?*
  • Do you have severe lower back pain?*
  • Do you have burning pain when passing urine?*
  • Are you passing more urine often than usual at night?*
  • Are you feeling or needing to pass urine more than usual?*
  • Do you have pain or discomfort in your lower tummy?*
  • Is your urine cloudy to the naked eye?*
  • Is there any blood in your urine?*
  • Do you have any level liver impairment?*
  • Do you have any level of kidney disease, or end stage renal disease may or may not requiring dialysis?*
  • Are you taking any other medication either prescribed or over the counter?*
  • Are you immunocompromised e.g. auto-immune disease, chemotherapy, immunosuppressant medication or HIV positive or abnormality of the urinary tract or ureteric stent?*
  • Are you suffering from G6PD deficiency?*
  • Are you suffering from blood dyscrasias or acute porphyria?*
  • Are you suffering from hyperkalaemia (high serum potassium level)?*
  • Are you suffering from diabetes, heart disease including Hypertension or renal dysfunction?*
  • Should be Empty: