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Pre-Exam Checklist

If you think you may have a urinary tract infection, it is important to make an appointment with your doctor or healthcare provider. If you don't, you may end up with a more serious infection.

If you are having symptoms but are unsure if they are symptoms of a UTI, you may want to fill out the Pre-Exam Checklist below. Print the completed checklist and bring it to your next doctor visit.

Pre-Exam Checklist

 I have a painful sensation while I'm urinating
 I have a burning sensation while I'm urinating.
 I often have a strong urge to urinate.
 I often feel the need to urinate, but when I do I only pass a small amount of urine.
 I have pain in my lower abdomen.
 When I urinate, my urine looks milky and/or cloudy.
 When I urinate, my urine has a foul smell.
  When I urinate, there is blood in my urine.
 I have a fever.
 I experience pain in the back or side below the ribs (flank pain)
 I feel nauseous and/or I am vomiting.
 I am a woman, and I experience an uncomfortable pressure above the pubic bone (suprapubic tenderness).
 I am a man, and I feel a sense of fullness in my rectum.

Health History Questions

Check all statements that are true for you.

 I have previously had a urinary tract infection.
 I have had a UTI within the past five years.
 I have had more than one UTI in my lifetime.
 I have had urinary tract surgery.
 I have abnormalities of the urinary tract.
 I have had urinary stones.
 I have diabetes.
 I have a parent or sibling with diabetes.
 I currently have a temporary urinary catheter.
 I currently have a permanent urinary catheter.
 I have another chronic medical condition.

Women:

 I have experienced menopause.
 I am currently experiencing menopause.

Men:

 I have, or have had, prostatitis.
 I have had prostatitis within the past five years.

What medication(s), if any, did your doctor or healthcare provider prescribe for you for urinary tract problems, and when did you finish your last treatment course?