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Acute Cystitis Form

Complete Your Appointment in 5 Simple Steps: Choose your type, fill in details, and confirm!

1

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Urinary tract infection in the male sex requires additional assessment. Please follow up with your doctor for your symptoms.

Patient Information

2

Previous episode(s) of UTI diagnosed?
Previous episode of UTI within last 1 month?
2 uncomplicated UTIs in 6 months or ≥3 uncomplicated UTIs in 12 months AND: a) patient takes a medication associated with increased risk of UTI (e.g. SGLT2 Inhibitor) OR  b) patient is interested in prophylactic therapy (e.g. postcoital antibiotic, ongoing antibiotic treatment)

Medical History

3

Drug History

4

Are any red flag symptoms present?
Are symptoms typical of acute uncomplicated cystitis?

Review of Symptoms

5

Available: Mon - Fri: 10 AM - 6 PM, Saturday: 10 AM - 2 PM

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