Cystitis Treatment Questionnaire

3. Are you pregnant, breastfeeding or trying to become pregnant?

Please tell us how many weeks pregnant you are:

4. Please select what symptoms you are experiencing:

Discomfort, burning or stinging sensation on passing urine
Passing urine more frequently than usual at night
Cloudy Urine
Blood in your urine
Cystitis symptoms for more than two days
Other

Please provide more details:

5.Do you have a fever, uncontrollable shivers, nausea, vomiting, or new pain around your mid back or sides?

The above symptoms suggest you may possibly have a severe urine infection that should be checked urgently by a doctor. You should not continue with this questionnaire but contact your GP or out of hours service immediately, or phone 111 to get advice about your treatment.

6. Are you feeling sleepy, lethargic or confused?

7. Do you have any abnormal vaginal discharge or itchiness of the vagina?

Please provide more details:

8. In the last twelve months, how many times have you been treated with antibiotics for cystitis?

None
Once or Twice
Three or more times

9. Have you ever had cystitis that has spread to your kidneys or required you to attend hospital?

Please provide more details:

10. Do you suffer from any of the following conditions?

• Kidney or liver impairment
• Blood disorders e.g. anaemia, glucose 6 phosphate dehydrogenase deficiency
• Acute porphyria (a disorder that causes skin sensitivity to light, pain attacks and muscle weakness).
• Folic acid deficiency
• Diabetes
• Any condition that suppresses your immune system
• Recent or major operations
• Neurological disorders: spinal cord injury, spina bifida

Please provide more details:

11. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Please provide more details:

12. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Please provide more details:

13. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Please provide more details:

14. Would you like us to pass on details of your treatment to your GP?

15. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

• You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
• I should seek urgent medical advice if I experience back pain or flu-like symptoms.
• You have answered the questions honestly and accurately and the treatment is solely for your personal use.
• You will read and understand the patient information leaflet supplied with your medication.
• You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
• You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
• You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet

Please click "Yes".