Urinary Tract Infection Symptoms - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home address

Medicare Card Number - IRN *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Tell us about your UTI symptoms

Frequent urge to urinate

Pain, stinging or burning sensation when passing urine

Foul smelling urine

Cloudy urine

Pain in pelvic area

Fever or chills

Nausea or vomiting

Fatigue or tired

Urinating specifics

Urinating more than usual

Inability to empty the bladder

Pain during or after urination

Urinary incontinence

Risk Factors

Had a previous UTI

Diabetes

Pregnant or possible pregnancy?

History of kidney stones

Previous urinary tract surgeries

Have a catheter

Had a recent urinary tract procedure (e.g. cystoscopy)

Other

Sexually active

Abnormal penile or vaginal discharge

Previous STI

Medical Background

Please list all your medical conditions (e.g. High Blood Pressure, Asthma, Diabetes)

Please list any medications you are currently taking.

Medications (Include Name, Dose and Frequency)

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Please upload any additional information.

Browse

Consent

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

Signature

Draw signature|Type signatureClear

Date