Hugglescote Surgery
Partners: Dr D Woods, Dr T Gauhar
Associate: Dr A Shah, Dr H Noble
Practice Manager: Keleigh Atkin
URINE SAMPLE FORM
To be filled in by anyone handing in a urine for testing (white top bottles)
Name of Patient:
Date of birth:
Present address of patient & contact telephone number:
REASON FOR TEST
Suspected urine infection
Dip for blood pressure
Early Morning urine for diabetes
Yes
Yes
Yes
No
No
No
SYMPTOMS – for people with suspected urine infection only
Pain on passing water
Frequently passing water
Pain in the lower abdomen
Pain on the loin (kidney area)
Blood in the urine
Vaginal discharge
Vaginal bleeding (eg: period)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
RESULTS OF URINE DIP TEST
Leucocytes
Nitrites
Blood
Protein
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
No
OUTCOME OF ANALYSIS
Sample sent to lab for further testing
Prescription supplied
Referred to GP
Comments:
Date of sample:
T: 01530 832109
F: 01530 832553
E: TBC
W: www.hugglescotesurgery.co.uk
Hugglescote Surgery
151 Grange Road
Coalville
Leicestershire LE67 2BS