UTI Pre-Consultation Intake Form
Please complete this form to help us understand your symptoms and medical history before your urinary tract infection consultation.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What symptoms are you currently experiencing? (Select all that apply)
*
Burning or pain during urination
Frequent urge to urinate
Cloudy or strong-smelling urine
Blood in urine
Lower abdominal pain or pressure
Fever or chills
Other
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had a urinary tract infection before?
*
Yes
No
Are you currently taking any medications? If yes, please list them.
*
Do you have any allergies to medications? If yes, please specify.
*
Are you pregnant or could you be pregnant?
*
Yes
No
Not applicable
Do you have any chronic medical conditions? (e.g., diabetes, kidney disease)
*
Submit
Should be Empty: