URINE SAMPLE
If under 12 years of age – SEE GP unless otherwise advised
Note: URINE SAMPLES are very difficult to interpret without this information
NAME……………………………………………………………………………….. DOB………………………………
TODAYS DATE and TIME of SAMPLE TAKEN………………./…………………/2015.
PLEASE CIRCLE ANSWER
ARE YOU DIABETIC?
ARE YOU PREGNANT?
DO YOU HAVE A CATHETER?
………………………..AM/PM
YES/NO
YES/NO
YES/NO
F YOU THINK YOU HAVE AN INFECTION PLEASE TICK THE FOLLOWING SYMPTOMS WHICH APPLY
 PAIN WHEN PASSING URINE
 GOING MORE OFTEN/URGENCY
 FEVERISH
 BACK and/or LOWER ABDOMINAL PAIN
 FEEL UNWELL
 OTHER – give details…………………………………………………………………………………………………
Can we e-mail back the result (please supply e-mail address)
YES/NO
………………………………………………………………………………………………….
or contact you by mobile (please supply current mobile number)
YES/NO
………………………………………………………………………………………………..
Or land line (please supply current land line number)
YES/NO
………………………………………………………………………………………………..
Can we leave a message
Editor: JMLP/My Docs/Mastercopies/Urine
January 2015
YES/NO