Urine Sample Proforma

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Urine Sample Proforma

Please complete the below questionnaire and submit along with your sample for analysis.

Please complete the questionnaire below

Please Note: You must contact the surgery for your result.

Date *

Name *

Date of Birth *

Address *

Tel No. *

Allergies *

Have you been asked by a health professional to leave a sample in? *

Yes No

if you answered yes to Q7, which health professional asked for a sample?

How long have you had symptoms? *

Select the follow that apply *

Discomfort passing urine

Passing urine more often

Urgent need to pass urine

Passing larger volume of urine

Noticed blood in urine

Temperature/shaking/chills

Lower abdominal pain

New back/flank pain

New Urinary incontinence

New/increased confusion/agitation

Vomiting

Vaginal Discharge/irritation

Pregnant/possibility of pregnancy

Have a urinary catheter inserted

Thank You for completing this questionnaire

Please contact the surgery for your result

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Page last reviewed: 23 July 2024

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