URINE SAMPLE
The surgery has introduced a new form to assist with testing your urine sample.
Please can you complete this form and hand into surgery with your urine sample?
Name……………………………………………………………………………………………………………
DOB…………………………. Age……………………………………………………
Date of specimen…………………………………………………………………………………………..
GP……………………………………………………………………………………………………………….
Please complete questions below.
Pain on passing urine |
Yes / No |
Passing urine more frequently |
Yes / No |
Pass a lot of urine |
Yes / No |
Pain in lower abdomen |
Yes / No |
Sudden urge to pass urine |
Yes / No |
Cloudy or smelly urine |
Yes / No |
Have a Temperature |
Yes / No |
Back pain |
Yes / No |
Vaginal Itching or discharge |
Yes / No |
Blood in urine |
Yes / No |
I am a diabetic this is early morning specimen |
Yes / No |
It is second sample following treatment for urine infection. |
Yes / No |
Sample to be checked for sugar |
Yes / No |
Sample request by |
Yes / No |
ARE YOU ALLERGIC TO ANY ANTIBIOTIC? YES / NO
IF SO WHICH ONE ……………………………………………………………………..
ARE YOU OR COULD YOU BE PREGNANT? YES / NO
THANK YOU FOR COMPLETING THIS FORM
FRESH FRACTIONAL URINE SPECIMEN H5MAPR0140 LEVEL III PURPOSE
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LAB VALUES NORMAL TEST URINE COMMENTS COLOR CLARITY SPEC
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