Reception: Urinary Tract Infection (UTI)

Urinary tract infections (UTIs) can affect different parts of your urinary tract, including your bladder (cystitis), urethra (urethritis) or kidneys (kidney infection). Most UTIs resolves with effective hydration to help flush infection out and in certain cases can be easily treated with antibiotics. Do not complete this form if you have had symptoms for 5 days or more.

UTI Self-help guide

UTIs can be a sign of a sexually transmitted infection. Get investigated for this

Urinary tract infections can become more severe and rarely lead to sepsis

If your symptoms worsen between completing this form and receiving a call from one of our GPs then please call to let us know or contact 111.

Call 111 immediately if you have any of these symptoms as they can suggest a kidney infection, which can be serious if it's not treated:

Pain in your sides or lower back
A high temperature (>37.9C) or you feel hot and shivery (shaking chills)
Feel sick or been sick
Muscle pains, flu like illness
Diarrhoea

This form is for NON-emergency queries. If you have a symptom listed above in red please call 111 immediately for advice. If the form is submitted before 2.00pm on a working day your query will be responded to on the same working day. For queries after 2.00pm this will be dealt with on the next working day. Please do not contact reception prior to this deadline unless your symptoms are getting worse as they will be unable to give you an update and all suspected UTIs are managed initially with this triage form. If you have any technical issues completing this form reception will assist you in completing it. If you feel your query is urgent call 111 for advice. If you are not a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Reception: Urinary Tract Infection (UTI)

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably a mobile number)

I confirm that I have had symptoms for less than 5 days

How long have you had the symptoms for?For patients experiencing symptoms for 5 days or more - Please do not send in a form, please call at 8.30am any weekday to and make a routine appointment with a GP

Does your urine look different to normal?

Do you have any burning or discomfort when you pass urine?

Are you going more frequently to pass urine?

Any discharge from your urethra (tube you pass urine from)?

Do you have any tummy pain?

Have you been able to drink & stay hydrated?

Have you been feeling feverish or shivery?

Do you have a recent history (within the last 3 years) of a sexually transmitted infection?Please note UTIs can be a sign of an sexually transmitted infection. Please click on the link above to find out how you can get investigated for this.

When was the last time you had a UTI?

How many UTIs have you had in the last 12 months?

Do you notice your symptoms are worsened after sexual intercourse?

Do you have any nausea (feeling sick) or vomiting?

Are you suffering any back pain?

Any further history?

Do you have any allergies to any medication? (if No state No below, otherwise state the medications you are allergic too)

Are you breast feeding or pregnant?

Have you experienced any weight loss?

I confirm I am happy to receive a response from the Dr by text if deemed appropriate.

Which pharmacy would you like us to send your medication too?

If other pharmacy please state NAME & POSTCODE

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Reception: Urinary Tract Infection (UTI)

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