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Cystitis Assessment

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

STOP. This consultation must be filled in by the female patient.

3. Are you female and over 18 years old?

The Family Chemist does not supply Cystitis medication to men or under 18s. Stop and see your GP.

4. Are you pregnant, breastfeeding or trying to become pregnant?

4b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are

5. Please select what symptoms you are experiencing:

You are less likely to need antibiotics if you only have one symptom.

6. Do you have a fever, uncontrollable shivers, nausea, vomiting, or new pain around your mid back or sides?

Please seek URGENT medical advice

7. Are you feeling sleepy, lethargic or confused?

Please seek URGENT medical advice

8. Do you have any abnormal vaginal discharge or itchiness of the vagina?

9. In the last twelve months, how many times have you been treated with antibiotics for cystitis?

10. Have you ever had cystitis that has spread to your kidneys or required you to attend hospital?

10b. Please provide more details:

11. Do you suffer from any of the following conditions?

  • Kidney or liver impairment
  • Blood disorders e.g. anaemia, glucose 6 phosphate dehydrogenase deficiency
  • Acute porphyria (a disorder that causes skin sensitivity to light, pain attacks and muscle weakness).
  • Vitamin B or Folic acid deficiency
  • Diabetes
  • Any condition that suppresses your immune system
  • Recent or major operations
  • Neurological disorders: spinal cord injury, spina bifida
  • allergies to nitrofurantoin/trimethoprim
  • lung disease including asthma

11b. Please provide more details:

12. You understand the following before ordering antibiotics:

Stop. You cannot continue with the consultation. You can change the answer once you understand.

  • The first choice is usually Nitrofurantoin, but it might not work for all.
  • Trimethoprim is not recommended for those over 75.
  • Only one antibiotic can be ordered.
  • The Family Chemist does not supply “standby” treatments.
  • If you have used trimethoprim within the last three months, it is recommended to opt for nitrofurantoin.

13. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

13b. Please provide more details:

14. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

14b. Please provide more details:

15. Are you allergic to any medicines or other substances e.g. peanuts or soya?

15b. Please provide more details:

16. Would you like us to pass on details of your treatment to your GP?

17. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

  • You will stop Nitrofurantoin and seek urgent medical advice if you suffer from shortness of breath, troublesome or painful breathing, coughing up blood or mucus, yellowing of the skin or eyes, upper abdominal pain, itching or join pain and swelling, pins and needles, severe headaches muscle weakness or other changes to the nervous system.
  • You have read the information on the treatments and medication web page and understand the side effects, their effectiveness and available alternatives.
  • I should seek urgent medical advice if I experience back pain or flu-like symptoms.
  • You have answered the questions honestly and accurately, and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet (Nitrofurantoin, Trimethoprim) supplied with your medication.
  • You understand that although it is not compulsory it is essential to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

18. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.