Q No.QuestionAnswer1Are you a female? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Are you suffering from severe symptoms of cystitis or do you have 3 or more of the following symptoms? • Cloudy urine • Increased frequency of urination (the need to urinate is more frequent than normal during the day, or at night, or both) • Dysuria (pain or discomfort on passing urine) • Urgency (delaying urination is more difficult) • Urine that smells offensive You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3I am aware that if the symptoms of cystitis do not improve within 48 hours after starting treatment I must contact my GP. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Some sexually transmitted diseases can cause cystitis; Are you aware you should urgently seek medical attention if you have had unprotected sex and have unusual symptoms, sores around the vagina, vaginal discharge or pelvic pain? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Do you suffer from kidney disease or are you having dialysis treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Are you diabetic? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Sometimes urinary infections can be more serious and require urgent review by your usual doctor or health care professional. Are you suffering with any of the following? • Abdominal pain • Haematuria (blood in the urine), which is visible to the unaided eye • Peri-anal or peri-vaginal itching • Reduced urine output • Raised temperature, nausea, dizziness, vomiting, fits, new or increasing malaise and confusion, racing heart, increased breathing rate or fainting • Pelvic tenderness • Vaginal discharge and/or offensive odour • Back pain • If you are postmenopausal and have vaginal discharge or itch, and pain during sexual intercourse You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8Have you ever suffered from any of the problems listed below? • Any type of blood disorder (e.g. anaemia) • Kidney disease • Deficiency of folic acid • Deficiency of glucose-6-phosphate dehydrogenase You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are you taking any of the following? If you are not sure consult the helpline. • Antibiotics such as rifampicin • Anticoagulants to prevent your blood clotting such as warfarin • Ciclosporin (to prevent rejection after transplantation) • Digoxin (to treat heart conditions) • Phenytoin (to treat epilepsy) • Pyrimethamine (to treat malaria) • Bone marrow depressants • Methotrexate • Cyclophosphamide • Allopurinol • Danazol • Tiaprofenic acid You must answer this question.You must answer this question.Please write your explanation in the box below Yes No10Do you agree to the following? • You will seek medical attention if you experience any unusual side effects • The treatment is solely for your own use • You will read the patient information leaflet supplied with your medication • You will seek medical attention if you develop a high fever or becomes systemically unwell • I am aware I can treat my symptoms with paracetamol or ibuprofen in addition to the antibiotic if required You must answer this question.You must answer this question.Please write your explanation in the box below Yes No11What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
