UTI Assessment

If you have been advised to submit a UTI assessment, please complete this form.

Please be aware that once this form has been submitted, it will be held within your health record.

UTI Assessment



Have you ever had a urinary tract infection before?
Do you have burning pain on passing urine?
Are you passing urine more often than usual at night?
Does your urine look cloudy?
Do you have to rush to get to the toilet to pass urine?
Are you passing urine more frequently than usual?
Have you seen any blood in your urine?
Are you experiencing any low tummy pain?
Have you had or do you feel like you have had a fever?
Do you have any new back pain high up under your ribs?
Do you feel nauseous or have you vomited?
Have you had a change in your vaginal discharge?
Have you had any new sexual partners in the last year?
Is there any possibility that you could be pregnant?