Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Cystitis (UTI) can be alleviated without the use of antibiotics. We would strongly advise that you use first line pain killers such as ibuprofen or paracetamol for the first two days.
If your symptoms persist after two days that is the only time you should consider taking antibiotics to treat your cystitis (UTI)
Are you aged over 65 years old?
Women that are over the age of 65 are more likely to require a longer course of antibiotics to treat their UTI to ensure the infection is properly treated. Failure to take a longer course can result in resistance and further complications. If you are unable to see your GP, you can call 111.
Have you been diagnosed with cystitis (UTI) in the past?
Are you experiencing any of the following symptoms?
You can select more than one.
Do you feel a strong desire to urinate and empty your bladder?
Are you passing urine more frequently than usual?
Does your urine appear to be cloudy or smell strong?
Are you experiencing lower abdominal pain and/or discomfort?
Is there any blood in your urine?
Are you currently experiencing lower back pain?
Please describe the pain and exact location
Are you currently experiencing nausea or vomiting?
Are you suffering from a high temperature or fever (above 38 celsius)?
Are you currently feeling lethargic or sleepy?
Do you suffer from any heart, kidney or liver problems?
Please provide more information
Do you suffer from any blood disorders?
Do you have a deficiency in folic acid?
Have you been diagnosed with porphyria (a disorder that causes photosensitivity of the skin (light sensitivity of the skin), muscle weakness and attacks of pain)?
Do you agree to seek urgent medical advice if you experience back pain or flu-like symptoms?
You agree not to take any UTI medication whilst pregnant or breastfeeding.
How many urinary tract infections (UTIs) have you had in the past 6 months?
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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