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UTI questionnaire

UTI Questionnaire

Section

Do you have any of the following symptoms?
Choose all that apply (you can select none)
Do you have any of the following symptoms?
Choose all that apply (you can select none)
Do you have any of the following symptoms?
Choose all that apply (you can select none)
How long have you had these symptoms?
What have you done to manage your symptoms?
Choose all that apply (you can select none)
Have you had a urinary tract infection before?
These are sometimes called bladder or water infection
Is there a possibility you might be pregnant?
Do you have a urinary catheter?
This is a tube that is inserted into your bladder which is used to empty the bladder and collect urine
If there is anything else you would like to share about your symptoms or any other relevant information regarding your UTI that has not been covered in this form, please provide details.