Pharmacy First Uncomplicated UTI Consultation

Patient Acknowledgement

By completing this consultation you agree to YourPharmacy’s Terms and Conditions and Privacy Policy.

Important Information

If you have any of these other conditions you must not wait for a response from us and contact your GP or 111.

Worsening lower back or side pain.

Vomiting

Fevers and shivering

For more information on managing Uncomplicated Urinary Tract Infections please click here: https://www.nhs.uk/conditions/urinary-tract-infections-utis/

I agree to the terms and I confirm none of the listed conditions apply to me

Name(Required)

These must match your NHS file

First Last

Date of Birth(Required)

What is your gender(Required)

This much match your NHS file

NHS number (if known)

Email Address(Required)

Phone Number(Required)

Street address(Required)

Address line 2

City(Required)

County / Region

Postcode(Required)

Have you had any new or unexpected vaginal bleeding/spotting?(Required)

Yes

I’m not sure

Have you had any missed or lighter periods?(Required)

Yes

I’m not sure

Is there a possibility you might be pregnant?(Required)

Yes

I’m not sure

Do have a condition or use any medications that cause a weakened immune system?(Required)

(For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV)

Yes

What is the cause of your weakened immune system?(Required)

Do you have any allergies?(Required)

Yes

Please specify more details(Required)

Please list any allergies and the reactions you have.

How many urinary tract infections have you had in the past year?(Required)

These are sometimes called bladder or water infection

Do you have a urinary catheter?(Required)

This is a tube that is inserted into your bladder which is used to empty the bladder and collect urine

Yes

What have you tried to manage your symptoms?(Required)

Choose all that apply (you can select none)

Painkillers e.g. paracetamol

Antibiotics

Cranberry products

Drinking more fluids

None of the above

Please specify more details(Required)

One of our pharmacists may need to contact you whilst they are processing your consultation, when would be the best time to contact you?

We can’t guarantee a time and will only contact you during opening hours, (Mon – Fri, 9am to 5pm)

Patient Agreement

By completing this consultation you agree to the following:

You answered all the questions correctly and to the best of your ability

You consent to YourPharmacy contacting you via phone or email to ensure the best possible care

You confirm you do not NEED URGENT medical attention, if so ring 999.

I agree

Pharmacy First Sore Throat Consultation

Patient Acknowledgement

By completing this consultation you agree to YourPharmacy's Terms and Conditions and Privacy Policy.

Important Information

You must not complete this consultation if you are experiencing any of the following

If any of these apply you must call 999 immediately

Difficulty breathing or swallowing.

Breathing that sounds abnormal or high-pitched.

A muffled or hoarse voice drooling.

If you have any of these other conditions you must not wait for a response from us and contact your GP or 111 immediately.

A weakened immune system

You are not producing as much urine as usual.

Feeling to unwell to care for yourself, for example simple tasks like washing or making food.

A fever with feeling generally weak, dizzy or excessively tired

I agree to the terms and I confirm none of the listed conditions apply to me

Name(Required)

These must match your NHS file

First Last

Date of Birth(Required)

What is your gender(Required)

This much match your NHS file

NHS number (if known)

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

How long have you had as sore throat?(Required)

Have you felt feverish in the past 24 hours?(Required)

Yes

Have you checked your temperature recently?(Required)

Yes

Please enter the reading below (°C)

Do you have a cough?(Required)

Yes

How long have you had the cough?(Required)

Do you have a blocked or runny nose?(Required)

Yes

Do you have a rash or does your skin feel rough, like sandpaper?(Required)

Yes

I'm not sure

Upload a Photo(Required)

Tips for taking a good photo

Make sure you have adequate lighting

Make sure the subject is clear and in focus.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Do you have any allergies?(Required)

Yes

Please specify more details(Required)

Please list any allergies and the reactions you have.

Do you have a condition or use any medications that cause you to have a weakened immune system?(Required)

For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV.

Yes

What is the cause of your weakened immune system?(Required)

Please select the statement that best suits your circumstance.(Required)

I am pregnant

I'm trying to conceive

I am breastfeeding

None of the above

One of our pharmacists may need to contact you whilst they are processing your consultation, when would be the best time to contact you?

We can’t guarantee a time and will only contact you during opening hours, (Mon - Fri, 9am to 5pm)

Patient Agreement

By completing this consultation you agree to the following:

You answered all the questions correctly and to the best of your ability

You consent to YourPharmacy contacting you via phone or email to ensure the best possible care

You confirm you do not NEED URGENT medical attention, if so ring 999.

I agree