Consultation - Your Pharmacy Clinic

UTI (Urinary Tract Infection)

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:Do you have any known allergies?

Question 2:Are you currently taking any medications?

Question 3:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Question 4:Have you had any surgeries in the past year?

Question 5:Do you smoke?

Question 6:Do you consume alcohol?

Question 7:How often do you exercise?

Question 8:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

2 About your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Question 1:How long have you been experiencing symptoms of a UTI?

Question 2:What symptoms are you currently experiencing? (e.g., burning sensation during urination, frequent urge to urinate, cloudy or strong-smelling urine, pelvic pain)

Question 3:Have you been diagnosed with a UTI by a healthcare professional?

Question 4:Have you had any tests to confirm the diagnosis? (e.g., urinalysis, urine culture)

Question 5:Have you identified any possible triggers that worsen your symptoms? (e.g., certain foods or drinks, sexual activity, hygiene practices)

Question 6:Have you been prescribed medication for UTIs before?

Question 7:Are you currently taking any medication for a UTI?

Question 8:Have you experienced any side effects from your current or past UTI medications?

Question 9:Have you tried any non-medication treatments for a UTI? (e.g., increased fluid intake, cranberry supplements, avoiding irritants)

Question 10:Have you used over-the-counter treatments for a UTI?

3 The Agreement and Consent

Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services.

Question 1:Understanding of Risks:

I have been informed about the potential side effects and interactions of the prescribed medication for UTIs.

Question 2:Medical Guidance:

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Question 3:Consent to Share Information:

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Question 4:Confirmation:

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

1 About your Health
2 About your Condition
3 The Agreement and Consent

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Assessment for Urinary Tract Infection (UTI)