Pharmacy First - Urinary Tract Infection (UTI) - The Family Chemist

1. Please provide the patient's details:

First Name *

Last Name *

Date of Birth *

Gender *

Email Address:

Postcode:

Phone Number:

Consent to Access Your Summary Care Records?

2. Please select which symptoms you're experiencing (select all that apply):

Pain or burning sensation when peeing

I am needing to pass urine more frequently, including during the night

I have cloudy urine

None of the above

2b. You may not be experiencing signs of a urinary tract infection, please contact your GP or a local pharmacy for review of your symptoms.

Thank you

We appreciate the time spent answering this questionnaire.

Your symptoms may need further investigation and we are unable to provide treatment through Pharmacy First, please visit your GP or contact NHS 111 for further advice and support.

3. Please select if any of the below symptoms apply:

I am pregnant

I have a urinary catheter in place

I have had 2 or more UTI infections in the past 6 months, or 3 or more in the past year

I have diabetes

I am currently on medication that dampens down my immune system

I have pain in my lower back/ under my ribs

I have flu like symptoms and a high temperature (38 or above)

I have experienced nausea and vomiting

None of the above

3b. Your symptoms may need further investigation and we are unable to provide treatment through Pharmacy First, please visit your GP or contact NHS 111 for further advice and support.

Thank you

We appreciate the time spent answering this questionnaire.

Your symptoms may need further investigation and we are unable to provide treatment through Pharmacy First, please visit your GP or contact NHS 111 for further advice and support.

4. Please select if any of the below symptoms apply (these might suggest that further review of your symptoms are required and we may signpost you to a suitable healthcare provider following our consultation):

Generally feeling unwell/ tired

Breathing faster than usual or difficulty breathing/ shortness of breath

Rapid or worsening symptoms such as nausea, vomiting or confusion

I am currently on medication that dampens down my immune system and my symptoms have gotten worse in the past day

None of the above

4b. Please select a suitable date and time to book your appointment for a video consultation on the next page. If you start feeling worse before the consultation, seek more urgent care.

Please book a priority consultation

Please follow the link below to book a priority consultation

Please note we will be able to tell you more and answer any questions during the consultation.

5. I can confirm that I have answered the questions to the best of my ability and I am experiencing the symptoms I have selected:

Yes

5b. Please select a suitable date and time to book your appointment for a video consultation on the next page. If you start feeling worse before the consultation, seek more urgent care.

We need to speak with you

We have gathered enough information

Please use the link below to go book an video call consultation about your conditions, please note we will be able to tell you more and answer any questions during the consultation.

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Pharmacy First – Urinary Tract Infection (UTI)

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

Opening times

Today’s Responsible Pharmacist

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