What does this Questionnaire do?
Pharmacies can offer advice and treatment for urinary tract infections (in women), new sinus problems, sore throats, ear infections, infected insect bites, impetigo and shingles, without a GP appointment or prescription.
The questionnaire link is sent via SMS or email. The patient fills in the questionnaire through a browser so they can use their phone, tablet, laptop or desktop to complete it.
The responses are returned to the user or organisation via the Accurx Web inbox. They can also be assigned to other colleagues.
Questions:
1. Do you have any of the following symptoms?
Choose all that apply (you can select none)
Discomfort or pain passing urine
Passing urine more frequently at night
Urine that is more cloudy
2. Do you have any of the following symptoms?
Choose all that apply (you can select none)
Feeling a sudden urgency to pass urine
Passing urine more frequently during the day
Urine that has visible blood in it
Discomfort or pain in the tummy
3. Do you have any of the following symptoms?
Choose all that apply (you can select none)
Feeling more confused
New pain in your lower back or sides
Nausea
Vomiting
Fever
Shivering
New muscle aches or symptoms of a flu-like illness
4. How long have you had these symptoms?
Less than 3 days
3 days - 1 week
1 - 2 weeks
More than 2 weeks
5. Are you currently sexually active?
This question is to help your healthcare professional understand the cause of your symptoms. Sometimes the symptoms of a urine infection are related to having sex.
Yes
No - not currently but I have been in the past
No - I have never been sexually active
Prefer not to say
6. Do you have any of the following symptoms?
Choose all that apply (you can select none)
New vaginal discharge
Smelly vaginal discharge
Vaginal dryness or irritation
Itchy vulva or vagina
Pain during or after sex
7. Have you had any new or unexpected vaginal bleeding/spotting?
Yes
No
I'm not sure
8. Have you had any missed or lighter periods?
Yes
No
9. Is there a possibility you might be pregnant?
Yes
No
10. Do you have a condition or use any medications that cause a weakened immune system?
For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV
Yes
No
If the patient answers yes to question 10 they will see question 11, if they answer no they skip to question 12👇
11. What is the cause of your weakened immune system?
Enter text.
12. How many urinary tract infections have you had in the past year?
These are sometimes called bladder or water infection
0
1
2
3
4 or more
13. Do you have a urinary catheter?
This is a tube that is inserted into your bladder which is used to empty the bladder and collect urine
Yes
No
14. What have you tried to manage your symptoms?
Choose all that apply (you can select none)
Painkillers e.g. paracetamol
Antibiotics
Cranberry products
Drinking more fluids
15. Do you have any allergies?
Yes
No
If the patient answers yes to question 15 they will see question 16, if they answer no they skip to question 17👇
16. Please list any allergies and what reaction you get with them
Enter text
17. Please tell us the best times to contact you.
We can’t guarantee a time and will only contact you during opening hours
Enter text
When they have submitted their answers, they will be thanked for completing the questionnaire and given some safety netting information 👇
If you still have any questions or concerns, feel free to chat with us using the green message bubble in the bottom right-hand corner of this page. 👉