URINE SAMPLE
The surgery has introduced a new form to assist with testing your urine sample.
Please can you complete this form and hand into surgery with your urine sample?
Name……………………………………………………………………………………………………………
DOB………………………….
Age……………………………………………………
Date of specimen…………………………………………………………………………………………..
GP……………………………………………………………………………………………………………….
Please complete questions below.
Pain on passing urine
Passing urine more frequently
Pass a lot of urine
Pain in lower abdomen
Sudden urge to pass urine
Cloudy or smelly urine
Have a Temperature
Back pain
Vaginal Itching or discharge
Blood in urine
I am a diabetic this is early morning
specimen
It is second sample following treatment
for urine infection.
Sample to be checked for sugar
Sample request by
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
No
No
No
No
No
No
No
No
No
No
No
Yes / No
Yes / No
Yes / No
ARE YOU ALLERGIC TO ANY ANTIBIOTIC?
YES / NO
IF SO WHICH ONE ……………………………………………………………………..
ARE YOU OR COULD YOU BE PREGNANT?
YES / NO
THANK YOU FOR COMPLETING THIS FORM
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