URINE SAMPLE THE SURGERY HAS INTRODUCED A NEW FORM

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URINE SAMPLE

URINE SAMPLE THE SURGERY HAS INTRODUCED A NEW FORM

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

733104.doc


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