Cystitis UTI TO BE COMPLETED

Are you experiencing cystitis at the moment?
If not please explain why you need this treatment.

Yes

No

Has your doctor already recommended Macrobid (nitrofurantoin) to treat cystitis?
If so, how successful was it?

Yes

No

Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.

Yes

No

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

What's your gender?

["Male"

"Female"

"Transmale (Born a female)"

"Transfemale (Born a male)"]

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

["Presently Pregnant"

" Presently Breastfeeding"

" Planning on getting pregnant"

" Neither Pregnant nor Breastfeeding"]

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Does any of these describe you?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Are you aware that if your symptoms do not improve after 48 hours, you should consult a doctor?
Do you require assistance?

Yes

No

Do you agree that you are not suffering any of the following symptoms and that if you do, you will seek medical attention:
Fever
Vomiting and nausea
Rash \sFainting
Pain in the back or stomach
Urine with blood

Do you require assistance?

Yes

No

In the last year, how many occurrences of cystitis have you had?
Choose one option.
Do you require assistance?

["Never"

" Once"

" Twice"

" Three times"

" Four or more times"]

Are you past 65 years of age?
Women who are over 65 years have higher chances of using antibiotics for longer periods for a successful treatment. You can call 111 if you are unable to visit your doctor.
Do you require assistance?

Yes

No

Has a certified medical practitioner diagnosed you with cystitis?
Do you require assistance?

Yes

No

Kindly identify the symptoms you are presently suffering
You can select more than one option
Do you require assistance?

["When you pee it burns or stings"

" Urine that is dark or hazy"

" Urine with a strong odor"

" Urinating in the middle of the night"

" Peeing frequently and urgently"

" Vaginal discharge that is unusual"]

Do you experience vaginal pain that isn't related to urinating (passing urine)?
If so, kindly elaborate on these sy

Yes

No

Have you any pain in your lower back or abdomen (tummy)?
We would grade pain on a scale of 1 to 5, with 5 being the worst pain you can imagine:
Mild discomfort 1–2 on a scale of 1–5
Moderate discomfort 3–4 stars out of 5
Severe discomfort 5.0 / 5.0 / 5.0 / 5.0 / 5.0 (worst pain you can imagine)
Choose one option.
Do you require assistance?

["None"

" Tender discomfort"

" Average discomfort"

" Serious discomfort"]

Have the cystitis symptoms changed from when you were first diagnosed by a doctor?
Do you require assistance?

Yes

No

Have you developed a fever or are you 'running a temperature'?

Yes

No

If you answered yes in the previous question, it is important to note that cystitis usually does not result in a fever. However, we can only ascertain that this is the most beneficial treatment for if you elaborate further that?
When you have a water infection, do you usually feel like this?
Do you have a physical ailment?
Do you have a feeling of weakness?
Are you sweating profusely?
Is the temperature suddenly rising and getting worse?

Has your doctor already recommended Trimethoprimto treat cystitis?
If so, how successful was it?

Yes

No

02476714834

Click to View

Sign up for our Newsletter

Get In Touch

Opening Hours

Cystitis UTI TO BE COMPLETED

Sign up for our Newsletter

Login Details

Please Register as a New Patient

Forgot Password ?