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2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3582 0000
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Urinary Tract Infections Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Please briefly describe your symptoms:

      3. Have you been diagnosed with cystitis in the past?

        If you have not had cystitis previously please see your regular doctor. We are unable to provide treatment for you.

        Yes

        No

        4. Are you allergic to trimethoprim or septrim (co-trimoxazole)?

          Please see your regular doctor. We are unable to prescribe trimethoprim for you.

          Yes

          No

          5. Have you been diagnosed with kidney damage or are you having dialysis treatment?

            Please see your regular doctor. We are unable to provide treatment for you.

            Yes

            No

            6. Have you been diagnosed with any blood disorders including anaemia and folic acid deficiency?

              Please consult with your GP before taking trimethoprim. We are unable to prescribe cystitis treatment for your.

              Yes

              No

              7. Are you taking any of the following medications?

              • Existing antibiotics - trimethoprim not to be taken with other antibiotics
              • Amiodarone - for irregular heart
              • Anticoagulants - for thinning the blood - includes warfarin
              • Ciclosporin - to prevent rejection after transplantation
              • Digoxin - for irregular heart and heart failure
              • Phenytoin - for epilepsy and fits
              • Pyrimethamine - malaria treatment
              • Azothioprine - taken to suppress immunity
              Please see your regular doctor. We are unable to provide treatment for you.

              Yes

              No

              8. Do you intend to take trimethoprim whilst pregnant or breast-feeding?

                Please see your regular doctor. We are unable to provide treatment for you.

                Yes

                No

                9. Are you aware the following symptoms would require urgent medical advice?

                • Back pain (Symptom of possible kidney infection)
                • Flu like symptoms (Fever, nausea and vomiting, rashes and collapse)
                These symptoms indicate a need for urgent medical attention. You can change your answer and continue.

                Yes

                No

                10. Are you aware cystitis symptoms should improve within 24 hours and resolve within 3 days of starting trimethoprim?

                • Symptoms not improving within 24 or not resolved within 3 days require medical assessment.
                Symptoms not improving within 24 or not resolving within 3 days require medical assessment. You can change your answer and continue.

                Yes

                No

                11. Do all the following apply to you?

                • I will read the patient information leaflet supplied with my tables.
                • The tablets are for my own use.
                • I am over 18.
                • I am female (We provide this antibiotic for women prone to cystitis NOT men)
                These conditions must apply. We are unable to provide treatment for you. Men with cystitis symptoms usually need to see a doctor face to face.

                Yes

                No

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