UTI questionnaire

Thank you for visiting us today and we’re sorry to hear about your symptoms. In this intake form, we will ask about your urinary symptoms and your medical history to guide safe, effective treatment of uncomplicated urinary tract infections (UTIs). For any signs of a complicated infection, or if you’ve had antibiotic-resistant UTIs before, an in-person evaluation is recommended to ensure timely, appropriate care.

Yes, I’m ready to move forward

I would like to stop this encounter

[HideColumn 66 in #of6bd0817706a][HideBlock #obca0a66ea4f8,#oe4ddf5b999ab][IfAnchor #aa.01][HideBlock #o709f4f0277e8][ShowBlock #oe4ddf5b999ab][Redirect #donetop][FillField f2323 with "Yes, I’m ready to move forward"][/IfAnchor][IfAnchor #aa.02][HideBlock #o709f4f0277e8][ShowBlock #obca0a66ea4f8][Redirect #donetop][/IfAnchor]

Your visit has been canceled

You chose not to proceed with this evaluation. No further action is required.

If you change your mind or need care later, you’re welcome to start a new visit at any time.

Find another visit type

Reproductive Health Screening

We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.

What was your sex assigned at birth?

Male

Female

[HideColumn 66 in #oe4ddf5b999ab][HideBlock #o7d7cbce87a25,#occ07e9ff126b][IfAnchor #sex.01][HideBlock #oe4ddf5b999ab][ShowBlock #o7d7cbce87a25][Redirect #donetop][FillField f2233//f2297 with "Male"][/IfAnchor][IfAnchor #sex.02][HideBlock #oe4ddf5b999ab][ShowBlock #occ07e9ff126b][Redirect #donetop][FillField f2233//f2297 with "Female"][/IfAnchor]

We’re sorry — we’re not able to treat this case online

What you were seeking help for:

• Urinary Tract Infection (UTI)

Why this happens

Urinary tract infections in men are less common and are often linked to underlying issues that need an in-person evaluation.

What to do next

Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

Find another visit type

Reproductive Health Screening

Are you currently pregnant or breastfeeding?

Yes

[HideColumn 66 in #occ07e9ff126b][HideBlock #o2eec809b91b2,#o02adab360d9e][IfAnchor #ab.01][HideBlock #occ07e9ff126b][ShowBlock #o2eec809b91b2][Redirect #donetop][FillField f2325 with "Yes"][/IfAnchor][IfAnchor #ab.02][HideBlock #occ07e9ff126b][ShowBlock #o02adab360d9e][Redirect #donetop][FillField f2325 with "No"][/IfAnchor]

We’re sorry — we’re not able to treat this case online

What you were seeking help for:

• Urinary Tract Infection (UTI)

Why this happens

Certain antibiotics commonly used for UTIs are not recommended during pregnancy or breastfeeding, and a provider may need to perform additional testing or choose medication based on an in-person assessment.

What to do next

Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

Find another visit type

Reproductive Health Screening

I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy or when breastfeeding. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus. By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.

I have read and understand the consent and wish to proceed

I do NOT wish to proceed

[HideColumn 66 in #o02adab360d9e][HideBlock #o4d986e7921b0][IfAnchor #ac.01][HideBlock #o02adab360d9e][ShowBlock #o4d986e7921b0][Redirect #donetop][FillField f2327 with "I have read and understand the above information, I understand the risks and wish to proceed"][/IfAnchor][IfAnchor #ac.02][HideBlock #o02adab360d9e][ShowBlock #obca0a66ea4f8][Redirect #donetop][FillField f2327 with "I have read the information and do NOT wish to proceed"][/IfAnchor]

Your measurements

What is your height?

What is your weight in pounds

Continue

[HideColumn 66 in #o4d986e7921b0] [HideBlock #o01d6143947f0] [IfField f2298 not '' and f2299 not '' and f2300 not ''][ShowElement 81 in #o4d986e7921b0][HideElement 82 in #o4d986e7921b0][/IfField] [IfAnchor #measurements.01][ShowBlock #o01d6143947f0][HideBlock #o4d986e7921b0][Redirect #donetop][/IfAnchor] [Calc f2233//f2298=f2298][Calc f2233//f2299=f2299][Calc f2233//f2300=f2300] [Validate #o4d986e7921b0-f2298 numeric "Must be Numeric values" force=yes][Validate #o4d986e7921b0-f2299 numeric "Must be Numeric values" force=yes][Validate #o4d986e7921b0-f2300 numeric "Must be Numeric values" force=yes][Validate #o4d986e7921b0-firstname IBAN “Please enter a valid IBAN” prevent=yes]

Validate

Submit

UTI History

Have you had a UTI in the past?

Yes

[HideColumn 66 in #o0ea27970b627][HideBlock #o16bea354ee76][IfAnchor #ad.01][ShowBlock #o16bea354ee76][HideBlock #o0ea27970b627][Redirect #donetop][FillField f2329 with "Yes"][/IfAnchor][IfAnchor #ad.02][ShowBlock #o8e7c76214f4c][HideBlock #o0ea27970b627][Redirect #donetop][FillField f2329 with "No"][/IfAnchor]

UTI History

How many urinary tract infections have you experienced in the past year?

[HideColumn 66 in #o16bea354ee76][HideBlock #o2e67ec4098bc][IfAnchor #ae.01][HideBlock #o16bea354ee76][ShowBlock #o2e67ec4098bc][Redirect #donetop][FillField f2331 with "None"][/IfAnchor][IfAnchor #ae.02][HideBlock #o16bea354ee76][ShowBlock #o2e67ec4098bc][Redirect #donetop][FillField f2331 with "One"][/IfAnchor][IfAnchor #ae.03][HideBlock #o16bea354ee76][ShowBlock #o2e67ec4098bc][Redirect #donetop][FillField f2331 with "Two"][/IfAnchor][IfAnchor #ae.04][HideBlock #o16bea354ee76][ShowBlock #o2e67ec4098bc][Redirect #donetop][FillField f2331 with "Three"][/IfAnchor][IfAnchor #ae.05][HideBlock #o16bea354ee76][ShowBlock #o2e67ec4098bc][Redirect #donetop][FillField f2331 with "Four or more infections"][/IfAnchor]

UTI History

Which antibiotics have you taken before for UTIs?

Nitrofurantoin (Macrobid)

Trimethoprim-sulfamethoxazole (Bactrim)

Fosfomycin (Monurol)

Fluoroquinolones (e.g., ciprofloxacin)

Other

[HideColumn 66 in #o2e67ec4098bc][HideBlock #oeb15dc1175fa][HideBlock #o4fcd4c27ab36][IfAnchor #af.01][HideBlock #o2e67ec4098bc][ShowBlock #o4fcd4c27ab36][Redirect #donetop][FillField f2333 with "Nitrofurantoin (Macrobid)"][/IfAnchor][IfAnchor #af.02][HideBlock #o2e67ec4098bc][ShowBlock #o4fcd4c27ab36][Redirect #donetop][FillField f2333 with "Trimethoprim-sulfamethoxazole (Bactrim)"][/IfAnchor][IfAnchor #af.03][HideBlock #o2e67ec4098bc][ShowBlock #o4fcd4c27ab36][Redirect #donetop][FillField f2333 with "Fosfomycin (Monurol)"][/IfAnchor][IfAnchor #af.04][HideBlock #o2e67ec4098bc][ShowBlock #o4fcd4c27ab36][Redirect #donetop][FillField f2333 with "Fluoroquinolones (e.g., ciprofloxacin)"][/IfAnchor][IfAnchor #af.05][HideBlock #o2e67ec4098bc][ShowBlock #oeb15dc1175fa][Redirect #donetop][FillField f2333 with "Other"][/IfAnchor]

UTI History

Did you have any problems with past treatments, like side effects or early recurrence? (multi-select)

Early recurrence (within two weeks)

Significant side effects

No complications

Continue

[HideColumn 66 in #o4fcd4c27ab36] [IfField f2377 is checked][ShowElement 88 in #o4fcd4c27ab36][/IfField] [IfField (f2375 is checked OR f2379 is checked) AND f2377 is unchecked][ShowElement 90 in #o4fcd4c27ab36][/IfField] [IfField f2375 is unchecked AND f2377 is unchecked AND f2379 is unchecked][ShowElement 89 in #o4fcd4c27ab36][/IfField] [SyncFields f2375,f2377,f2379] [HideBlock #o9476385555d1][HideBlock #o8e7c76214f4c][IfAnchor #past.01][ShowBlock #o9476385555d1][HideBlock #o4fcd4c27ab36][Redirect #donetop][/IfAnchor][IfAnchor #past.02][ShowBlock #o8e7c76214f4c][HideBlock #o4fcd4c27ab36][Redirect #donetop][/IfAnchor]

Submit

Sexual & Vaginal Symptoms

Do any of the following apply to you? (Select all that apply)

I have recently had unprotected intercourse with a new partner

I have recently had a sexually transmitted infection (STI/STD)

I’m having vaginal discharge

I’m having vaginal itching

I have liver cirrhosis

I have chronic kidney disease (CKD) stage 3b and beyond

None of the above apply to me

Continue

[HideColumn 66 in #o8e7c76214f4c] [IfField f2403 is unchecked AND f2405 is unchecked AND f2407 is unchecked AND f2409 is unchecked AND f2411 is unchecked AND f2413 is unchecked AND f2415 is unchecked][ShowElement 89 in #o8e7c76214f4c][/IfField][IfField f2403 is checked OR f2405 is checked OR f2407 is checked OR f2409 is checked OR f2411 is checked OR f2413 is checked][ShowElement 88 in #o8e7c76214f4c][/IfField][IfField f2415 is checked][ShowElement 91 in #o8e7c76214f4c][/IfField] [IfField f2415 is checked][FillField f2403,f2405,f2407,f2409,f2411,f2413 with unchecked][/IfField][IfField f2403 is checked OR f2405 is checked OR f2407 is checked OR f2409 is checked OR f2411 is checked OR f2413 is checked][FillField f2415 with unchecked][/IfField] [SyncFields f2403,f2405,f2407,f2409,f2411,f2413,f2415] [HideBlock #ofcc99802bf25][IfAnchor #svssympt.02][ShowBlock #ofcc99802bf25][HideBlock #o8e7c76214f4c][Redirect #donetop][/IfAnchor][IfAnchor #svssympt.01][ShowBlock #o540662deb810][HideBlock #o8e7c76214f4c][Redirect #donetop][/IfAnchor]

Submit

Your Symptoms

Tell us what you're experiencing. (Select all that apply)

Burning when I urinate

Urinating frequently

Sudden urge to urinate

Discomfort in my lower pelvis

Cloudy or foul-smelling urine

Blood in my urine

Other

Continue

[HideColumn 66 in #ofcc99802bf25][SyncFields f2417,f2419,f2421,f2423,f2425,f2427,f2429] [IfField f2417is unchecked AND f2419is unchecked AND f2421is unchecked AND f2423is unchecked AND f2425is unchecked AND f2427is unchecked AND f2429 is unchecked][ShowElement 89 in #ofcc99802bf25][/IfField][IfField (f2417 is checked OR f2419 is checked OR f2421 is checked OR f2423 is checked OR f2425 is checked OR f2427 is checked) AND f2429 is unchecked][ShowElement 88 in #ofcc99802bf25][/IfField][IfField f2429 is checked][ShowElement 91 in #ofcc99802bf25][/IfField] [HideBlock #oc6234b165221][HideBlock #o3042e860648d][IfAnchor #symptoms.01][ShowBlock #oc6234b165221][HideBlock #ofcc99802bf25][Redirect #donetop][/IfAnchor][IfAnchor #symptoms.02][ShowBlock #o3042e860648d][HideBlock #ofcc99802bf25][Redirect #donetop][/IfAnchor]

Submit

Warning Signs

Do you have any of these symptoms? (Select all that apply)

I have had a fever of 100.4 °F or higher, or I have had chills

New flank (side) or back pain since symptoms started

Nausea or vomiting preventing you from keeping fluids or pills down

Confusion or changes in mental status

I do not have any of the above

Continue

[HideColumn 66 in #oc6234b165221][SyncFields f2431,f2433,f2435,f2437,f2439] [IfField f2431 is checked OR f2433 is checked OR f2435 is checked OR f2437 is checked OR f2439 is checked][HideElement 89 in #oc6234b165221][/IfField][IfField f2431 is checked OR f2433 is checked OR f2435 is checked OR f2437 is checked][ShowElement 88 in #oc6234b165221][/IfField][IfField f2439 is checked][ShowElement 91 in #oc6234b165221][/IfField] [IfField f2431 is checked OR f2433 is checked OR f2435 is checked OR f2437 is checked][FillField f2439 with unchecked][/IfField][IfField f2439 is checked][FillField f2431,f2433,f2435,f2437 with unchecked][/IfField] [HideBlock #o540662deb810][HideBlock #oc2fc8a1d799c][IfAnchor #notany.01][ShowBlock #o540662deb810][HideBlock #oc6234b165221][Redirect #donetop][/IfAnchor][IfAnchor #notany.02][ShowBlock #oc2fc8a1d799c][HideBlock #oc6234b165221][Redirect #donetop][/IfAnchor]

Submit

Complicating Conditions

Do you have any of the following conditions?

Kidney stones or urinary tract abnormalities

Voiding dysfunction or neurogenic bladder

Indwelling catheter or recent catheter use

Immunocompromised condition (HIV, chemotherapy)

Uncontrolled diabetes

None of the above

Continue

[HideColumn 66 in #oc2fc8a1d799c][SyncFields f2391,f2393,f2395,f2397,f2399,f2401] [IfField f2391 is checked OR f2393 is checked OR f2395 is checked OR f2397 is checked OR f2399 is checked OR f2401 is checked][HideElement 89 in #oc2fc8a1d799c][/IfField][IfField f2391 is checked OR f2393 is checked OR f2395 is checked OR f2397 is checked OR f2397 is checked][ShowElement 88 in #oc2fc8a1d799c][/IfField][IfField f2401 is checked][ShowElement 91 in #oc2fc8a1d799c][/IfField] [IfField f2391 is checked OR f2393 is checked OR f2395 is checked OR f2397 is checked OR f2397 is checked][FillField f2401 with unchecked][/IfField][IfField f2401 is checked][FillField f2391,f2393,f2395,f2397,f2399 with unchecked][/IfField] [HideBlock #o23a48adbb650] [IfAnchor #conditions.01][ShowBlock #o540662deb810][HideBlock #oc2fc8a1d799c][Redirect #donetop][/IfAnchor][IfAnchor #conditions.02][ShowBlock #o23a48adbb650][HideBlock #oc2fc8a1d799c][Redirect #donetop][/IfAnchor]

Submit

Complicating Conditions

When did your urinary symptoms start?

Within 1–3 days

Within 4–7 days

More than 7 days ago

[HideColumn 66 in #o23a48adbb650][HideBlock #o8f2739baf432][IfAnchor #aj.01][HideBlock #o23a48adbb650][ShowBlock #o8f2739baf432][Redirect #donetop][FillField f2341 with "Within 1–3 days"][/IfAnchor][IfAnchor #aj.02][HideBlock #o23a48adbb650][ShowBlock #o8f2739baf432][Redirect #donetop][FillField f2341 with "Within 4–7 days"][/IfAnchor][IfAnchor #aj.03][HideBlock #o23a48adbb650][ShowBlock #o8f2739baf432][Redirect #donetop][FillField f2341 with "I have been present for >7 days"][/IfAnchor]

Timeline & Previous Treatment

Have you already received treatment for your current symptoms?

Yes, I was prescribed medication but my symptoms are still present

Yes, I tried over-the-counter supplements but no antibiotics

No, I haven’t tried anything yet

[HideColumn 66 in #o8f2739baf432][HideBlock #o39a057d0abcf][IfAnchor #ak.01][ShowBlock #o540662deb810][HideBlock #o8f2739baf432][Redirect #donetop][FillField f2343 with "Yes, I have already treated this with a prescription medication but my symptoms are persistent"][/IfAnchor][IfAnchor #ak.02][ShowBlock #o39a057d0abcf][HideBlock #o8f2739baf432][Redirect #donetop][FillField f2343 with "Yes, I have tried other over the counter supplements but I have not taken an antibiotic"][/IfAnchor][IfAnchor #ak.03][ShowBlock #o39a057d0abcf][HideBlock #o8f2739baf432][Redirect #donetop][FillField f2343 with "No, I haven’t tried anything yet"][/IfAnchor]

Timeline & Previous Treatment

Treatment without a urine culture may affect later test results. Certain factors can increase the risk of resistant bacteria.

Do any of the following apply to you? (Select all that apply)

I understand the risk, I do not have any of these factors, and I agree to treatment without a urine culture

I have recently used antibiotics within the last 90 days

I have a history of resistant bacteria

I have risk factors including a recent hospital admission or travel within the last 90 days

I’m concerned about these risks and would like to stop this encounter (End visit)

Continue

[HideColumn 66 in #o39a057d0abcf][SyncFields f2381,f2383,f2385,f2387,f2389] [IfField f2381 is unchecked AND f2383 is unchecked AND f2385 is unchecked AND f2387 is unchecked AND f2389 is unchecked][ShowElement 89 in #o39a057d0abcf][/IfField][IfField f2381 is checked][ShowElement 88 in #o39a057d0abcf][/IfField][IfField f2383 is checked OR f2385 is checked OR f2387 is checked OR f2389 is checked][ShowElement 91 in #o39a057d0abcf][/IfField] [IfField f2383 is checked OR f2385 is checked OR f2387 is checked OR f2389 is checked][FillField f2381 with unchecked][/IfField][IfField f2381 is checked][FillField f2383,f2385,f2387,f2389 with unchecked][/IfField] [HideBlock #o0c1c4486c515] [IfAnchor #previous.01][ShowBlock #o0c1c4486c515][HideBlock #o39a057d0abcf][Redirect #donetop][/IfAnchor][IfAnchor #previous.02][ShowBlock #o540662deb810][HideBlock #o39a057d0abcf][Redirect #donetop][/IfAnchor]

Submit

We’re sorry — we’re not able to treat this case online

Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

Why this happens

Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.

What to do next

Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

Find another visit type

Telemedicine Consent

I understand that I am engaging in a telemedicine (remote) medical encounter with a qualified healthcare provider for the evaluation and treatment of symptoms suggestive of a urinary tract infection (UTI).

Potential Benefits:

Timely access to care and treatment without needing to travel
Convenient communication and prescription delivery through the telemedicine platform

Potential Limitations and Risks:

Diagnostic Limitations: Without a urine culture, the diagnosis is based on symptoms and may not identify atypical or resistant organisms
Treatment Risks: Empiric antibiotic therapy may not be effective if the causative bacteria are resistant
Delayed Diagnosis: If symptoms persist or worsen, further testing (e.g., in-person urine culture) may be required, potentially prolonging illness
Side Effects: All antibiotics carry risks (e.g., gastrointestinal upset, allergic reactions). I will review and follow the medication instructions carefully
Referral: If red-flag symptoms develop (e.g., fever >100.4°F, flank pain, vomiting, confusion), I will seek in-person or emergency care

Alternatives to Telemedicine:

In-person evaluation with a healthcare provider, including physical exam and on-site urine testing
Visit to an urgent care or emergency department if symptoms are severe

Patient Responsibilities:

Provide accurate and complete medical history, including allergies and past antibiotic use.
Report any changes in symptoms promptly.
Adhere to prescribed treatment plan and follow-up instructions.

By signing below, I acknowledge that I have read and understand the information above, and agree to proceed with telemedicine-based evaluation and empiric treatment of my suspected UTI.

I have read and understand the consent and wish to proceed

I do NOT wish to proceed

[HideColumn 66 in #o36050e017fed][HideBlock #o6d39b139f5ed][HideBlock #oce63a26a2a2d][IfAnchor #am.01][HideBlock #o36050e017fed][ShowBlock #o6d39b139f5ed][Redirect #donetop][FillField f2347 with "I have read the above information and I do consent and wish to move forward"][/IfAnchor][IfAnchor #am.02][HideBlock #o36050e017fed][ShowBlock #oce63a26a2a2d][Redirect #donetop][FillField f2347 with "I have read the above information and I do not wish to continue"][/IfAnchor]

Verification

Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

I consent and wish to move forward

I do NOT wish to continue (End visit)

[HideColumn 66 in #o36050e017fed] [IfAnchor #an.01][FillField f2349 with "I have read the above information and I do consent and wish to move forward"][Submit #o46e5a9d95484][/IfAnchor][IfAnchor #an.02][HideBlock #o36050e017fed][ShowBlock #oce63a26a2a2d][Redirect #donetop][FillField f2349 with "I have read the above information and I do not wish to continue"][/IfAnchor]

Your visit has been canceled

You chose not to proceed with this evaluation. No further action is required.
If you change your mind or need care later, you’re welcome to start a new visit at any time.

Find another visit type

Cookie Settings

UTI questionnaire

Your visit has been canceled

Reproductive Health Screening

We’re sorry — we’re not able to treat this case online

What you were seeking help for:

Why this happens

What to do next

Reproductive Health Screening

We’re sorry — we’re not able to treat this case online

What you were seeking help for:

Why this happens

What to do next

Reproductive Health Screening

Your measurements

Medical background

UTI History

UTI History

UTI History

UTI History

UTI History

UTI History

Sexual & Vaginal Symptoms

Your Symptoms

Your Symptoms

Warning Signs

Complicating Conditions

Complicating Conditions

Timeline & Previous Treatment

Timeline & Previous Treatment

We’re sorry — we’re not able to treat this case online

Why this happens

What to do next

Additional Information

Telemedicine Consent

Verification

Your visit has been canceled

UTI questionnaire​​​​​​​​​​​​​​

What you were seeking help for:

Why this happens

What to do next​​​​​​​

What you were seeking help for:

Why this happens

UTI History

Sexual & Vaginal Symptoms​​​​​​​

Your Symptoms

Warning Signs

Complicating Conditions

Timeline & Previous Treatment

UTI questionnaire

What to do next

Sexual & Vaginal Symptoms