UTI Treatment Eligibility Screening
Answer the questions to confirm you’re eligible for pharmacist-guided UTI treatment or need referral to primary care.
Name
*
First Name
Last Name
What is your date of birth? MM-DD-YYYY
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you between the ages of 12 - 54 years old?
*
Yes
No
Are you currently pregnant or breastfeeding?
*
Yes
No
Have you had 4 or more urinary tract infections (UTIs) within the past 6 months?
*
Yes
No
Are you currently experiencing any of the following symptoms? Fever greater than 99.9°F, chills, shaking or severe chills (feeling very cold or very hot), significant fatigue or exhaustion, a general feeling of illness or discomfort, pain or tenderness in your side or lower back (flank pain), nausea or vomiting.
*
Yes
No
Are you currently experiencing any of the following typical UTI symptoms?
*
Rows
Yes
No
Pain or burning sensation during urination
Frequent urination, sudden urge to urinate or difficulty holding in urine
Pain in the side of the body and pelvic region
Cloudy, strong or foul-smelling urine
Are you currently experiencing any of the following symptoms?
*
Rows
Yes
No
Fever greater than 99.9°F or chills
Shaking or severe chills (feeling very cold or very hot)
Significant fatigue or exhaustion
A general feeling of illness or discomfort
Pain or tenderness in your side or lower back (flank pain)
Nausea or vomiting
Are you currently experiencing any of the following more significant symptoms?
*
Rows
Yes
No
Difficulty breathing or shortness of breath
Pain or pressure in your chest or abdomen
Severe or persistent vomiting
Dehydration, dizziness, or very little to no urination in the past 24 hours
Decreased alertness or awareness
Sudden numbness or weakness of your face, arm, leg, or one side of your body
Sudden confusion, difficulty speaking, or trouble understanding speech
Trouble seeing in one or both eyes
Trouble walking, loss of balance, or poor coordination
Are you currently experiencing any of the following symptoms that could indicate something other than a UTI?
*
Rows
Yes
No
Foul-smelling or unusual vaginal discharge
Pain during sexual intercourse
Itching or irritation in the genital area
Unusual vaginal bleeding or genital sores
Do you have a history of any of the following conditions?
*
Rows
Yes
No
Urinary stricture (narrowing of the urinary tract)
A condition that weakens your immune system (for example, blood cancer, advanced HIV, neutropenia, or long-term steroid use)
Kidney stones
Kidney transplant
Uncontrolled diabetes or high blood sugar
Current use of a urinary catheter
Are you currently experiencing any of the following emergency warning signs? Difficulty breathing or shortness of breath, pain or pressure in your chest or abdomen, severe or persistent vomiting, dehydration, dizziness, or very little to no urination in the past 24 hours, decreased alertness or awareness, sudden numbness or weakness of your face, arm, leg, or one side of your body, sudden confusion, difficulty speaking, or trouble understanding speech, trouble seeing in one or both eyes, trouble walking, loss of balance, or poor coordination.
*
Yes
No
Are you currently experiencing any of the following symptoms? Foul-smelling or unusual vaginal discharge, pain during sexual intercourse, itching or irritation in the genital area, unusual vaginal bleeding or genital sores.
*
Yes
No
Do you have a history of any of the following conditions? Urinary stricture (narrowing of the urinary tract), a condition that weakens your immune system (for example, blood cancer, advanced HIV, neutropenia, or long-term steroid use), kidney stones, kidney transplant, uncontrolled diabetes or high blood sugar, current use of a urinary catheter.
*
Yes
No
Your health information is confidential and will only be reviewed by our clinical team.
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