| 1 | Are you a female?
You must answer this question. You must answer this question. | |
| 2 | Are 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. | |
| 3 | I 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. | |
| 4 | Some 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?
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| 5 | Do you suffer from kidney disease or are you having dialysis treatment?
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| 6 | Are you diabetic?
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| 7 | Sometimes 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. | |
| 8 | Have 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. | |
| 9 | Are 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. | |
| 10 | Do 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. | |
| 11 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
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