Request Antibiotics For Simple Urine Infection (Female adults 66 years and older)

Full Name: *

Date of Birth: *

(Please use this format DD/MM/YYYY)

Phone Number: *

Email Address: *

(Any responses we send will go to this email address)

My symptoms include:

New discomfort as I pass urine:

Yes

No

Or

I need to pass urine more frequently (which is new for me):

Yes

No

An urgent feeling that I need to pass urine (which is new for me):

Yes

No

I am wetting myself (which is new for me):

Yes

No

I confirm that:

I think this is a mild urine infection:

I think this is a mild urine infection

I do NOT have a fever:

I do NOT have a fever

I am NOT significantly unwell:

I am NOT significantly unwell

I do NOT have any significant problems with antibiotics:

I do NOT have any significant problems with antibiotics

I do NOT have complicated urinary/kidney problems:

I do NOT have complicated urinary/kidney problems

I have NOT seen blood in the urine:

I have NOT seen blood in the urine

I do NOT have complicated infections or repeated urine infections:

I do NOT have complicated infections or repeated urine infections

I am NOT vomiting:

I am NOT vomiting

I am passing near/normal volumes of urine:

I am passing near/normal volumes of urine

I do NOT have abdominal or loin/kidney pains:

I do NOT have abdominal or loin/kidney pains

I do NOT have a catheter:

I do NOT have a catheter

I do NOT have a significant medical problems that might alter the assessment:

I do NOT have a significant medical problems that might alter the assessment

If you have been unable to meet all the safety criteria above then please contact the practice when open or 111 service in the out of hours period as a clinician will need to assess you further before proceeding.

Nitrofurantoin/Trimethoprim/Pivmecillinam are commonly prescribed antibiotics for urine infections.

Once your request has been assessed, the clinician will contact you and this might be by text message to let you know that they are sending a prescription to your usual pharmacy. If you feel more unwell please seek urgent clinical advice instead.

The link below gives advice about how to help yourself and what to do if your symptoms change.

www.rcgp.org.uk/clinical-and-research/resources

*

I confirm that am not unwell and only have a simple/mild urine infection and that if I am more unwell I will seek urgent medical advice.

*

I understand that after 4pm I must phone the practice if needing a reply before the next working day.

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Request Antibiotics For Simple Urine Infection (Female adults 66 years and older)

Request Antibiotics For Simple Urine Infection (Female adults 66 years and older)

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