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UTI Test Results Form

Gender
Female
Male
Non-binary
Other
Does the patient use incontinence products?
Yes
No
Has the patient had a diagnosed UTI in the past 12 months?
Yes
No
Unsure
What are the patients symptoms of the UTI? (check all that apply)
How long have these symptoms been present?
Less than 24 hours
1-3 days
3+ days
Test result
Positive
Negative
Inconclusive
Is an antibiotic being prescribed by a pharmacist?
Yes
No
Maybe
Was the patient referred to a doctor?
Yes
No
Maybe

All data is private and confidential, only to be used for the purpose of the Connecting Care Niagara UTI study. Thank you for helping us bring more awareness to bladder health!


If you have any questions please contact us at connectingcareniagara@outlook.com

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