Urine Sample/UTI Assessment Form

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Urine Sample/UTI Assessment Form

Please complete the sections below and submit to the practice, if asked to do so by a member of staff.

Please complete the following questions

Name of GP Practice *

Patient Name *

Date of Birth *

Age *

Sex *

Male

Female

Prefer not to answer

Symptoms - tick all that apply *

Pain or burning when passing urine

Passing urine more often/urgently than usual

Cloudy urine

Getting up at night to pass urine more than usual

Other

Blood in urine

Have you had 2 or more UTI's in the past 6 months? *

Yes No

Have you had 3 or more UTI's in the past 4 years *

Yes No

Do you have any allergies (including medicine allergies)? If yes, please specify:

Are you or could you be pregnant?

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Page last reviewed: 21 October 2026

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