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Health Questions
Please answer the following questions to help us assess your suitability for treatment
What is your biological gender at birth?
*
Male
Female
Are you aged between 18-65?
*
Yes
No
Are you pregnant, breastfeeding or is there a possibility that you could be pregnant?
*
Yes
No
Have you had any vaginal discharge in the past week?
*
Yes
No
Do you have a catheter (a urine drain tube) inserted?
*
Yes
No
Has this infection started after a recent operation or other surgical procedure?
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Yes
No
Have you treated a urine infection with antibiotics in the last 6 months?
*
Yes
No
Do you have at least two of the following symptoms?
*
Discomfort, stinging or burning when you pass urine
Cloudy urine
An increase in the number of times you need to pass urine at night?
Yes
No
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