top of page
Questionnaire for
Urinary Tract Infection
Are you a female?
Are you aged between 18 and 65?
Are you currently breastfeeding, pregnant or planning to become pregnant?
If you are still having periods, is your period late or have you missed your last period?
Have you developed a new vaginal discharge in the last week?
Do you have a catheter (a plastic tube) inserted it into the bladder?
Has your infection followed an operation or other surgical procedure?
Have you had antibiotics for a urinary infection in the last month?
Have you seen blood when you pass urine?
Do you experience adverse reactions or have allergies (hypersensitivity) to lactose, or any medications?
Currently taking any medications? This includes over-the-counter, prescriptions and recreational drugs.
Do you agree with the folllowing statement below?

You will contact us if you experienced side effects from the treatment, start new medication or
develop or have a change in your medical condition.


The treatment is solely for you in your own use.


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly, and that incorrect information can be hazardous to your health.


You will read the patient information leaflet supply with your medication.


You will notify your primary care physician about your treatment from PBJ medical associates.

Thanks. We'll get back to you soon.

bottom of page