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Questionnaire for
Urinary Tract Infection
Are you a female? Required
Are you between 18 and 65? Required
Are you currently breastfeeding, pregnant or planning to become pregnant? Required
Are still having your cycle, has your cycle been irregular? Required
Have you been experiencing vaginal discharge in the last week? Required
Do you have any of the following symptoms or conditions? Required
Do you have a catheter (a plastic tube) inserted it into the bladder? Required
Have you recently had fever or chills? Required
Have you had antibiotics for a urinary infection in the last month? Required
Have you had any pain in your lower back or abdomen ? Required
Do you have any of the following symptoms or conditions?
Any known allergies or have you experinced adverse reactions to any medications? Required
Are you currently taking any medications? This includes over-the-counter, prescriptions and recreational drugs. Required
Do you agree with the folllowing statement below? Required

Please contact us if you experienced any side effects from the treatments. If you start new medication,
or developed any changes in your medical condition, please contact PBJ Medical Rx. 


The treatment is solely for your own use. An information leaflet will be supplied with your medication.

You will notify your primary care physician about your treatment from PBJ Medical Rx


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly. If incorrect information has been received inappropriate clinical decisions can be made and may be harmful to your health.

 

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Thanks. We'll get back to you soon.

PBJ Medical RX

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​VISIT

7380 West Sand Lake Road

Orlando, FL 32819

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​CONTACT US

(800) 485-7962
info@pbjmedicalrx.com

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Medical Discliamer - PBJ Medial Associates LLC

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