Request for urine testing

You have asked for a urine sample to be checked.

Although this may seem strange there is often no value in testing a urine sample. We need more information to help us to know whether the urine sample should be tested and what tests to do, or whether we should give some treatment straight away, or whether the you/the patient needs to see a doctor or nurse.

Please answer all the following questions. The information will be passed to a doctor or nurse who will then be able to decide what to do. It is very important for us to have this information, and we will not be able to do anything more without it.

Date of Birth
Today's Date

Does you have any of the following symptoms?

Passing Water more often than usual
Pain on passing water
Needing to get to the loo very quickly to pass water
Pain or discomfort in the lower tummy
Vaginal itching or discharge
Pain in the sides of the tummy
NEW back pain
Blood in the urine
NEW confusion or confusion that is worse than usual
Does you have a catheter?
Have you had antibiotics recently (for a water infection) but not feeling better?