English Questionnaire for urine testing - Huisarts Gezondheidscentrum Brakkenstein

Questionnaire for urine testing

(please fill in completely or circle the correct answer)

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Surname & initials *

Email address *

Date of birth *

Kept cool *

Yes

No

Since when complaints *

Date *

Time urine collection *

Pain / burning when urinating *

Yes

No

Urinating more often *

Yes

No

Urinating small amounts *

Yes

No

Pain in the lower abdomen or back *

Yes

No

Fever (above 38ᵒC) *

Yes

No

Severe chills *

Yes

No

Flank pain (kidney region) *

Yes

No

Confused *

Yes

No

Urine has been In the bladder for more than 2 hours *

Yes

No

Can have STD (venereal disease) *

Yes

No

Diabetes *

Yes

No

Complaints regonizable from previous cystitis *

Yes

No

Had a bladder infection last year *

Yes

No

Urine from indwelling catheter *

Yes

No

For Female:

Increased vaginal discharge

Yes

No

Currently having your period

Yes

No

Pregnant

Yes

No

For men:

Dicharge form penis

Yes

No

Space for comments (e.g. allergy to antibiotics, kidney problem, other details):

Thank you for completing. You can call us back after 15:00 hour for the result.
For assistant, assessment stick: leuko’s, nitriet, prot ery’s

Questionnaire for urine testing

Questionnaire for urine testing

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