UTI Survey 「*」は必須フィールドを示します RealTime Laboratory (RTL) Urinary Tract Infection Questionnaire (To be filled out by the Patient). (It is necessary that this form be completed in its entirety prior to the health care provider ordering a UTI test). Todays Date: 05/08/2025Full Name* 名 姓 Gender* Male Female Date of Birth* MM スラッシュ DD スラッシュ YYYY Email Address* Phone Number*Known Allergies* Yes No Please explainPlease select either yes or no to questions 1 and 21. Do you have any of the following symptoms?Discomfort or pain passing urine*Please selectYesNoPassing urine more frequently*Please selectYesNoInability or difficulty passing urine*Please selectYesNoUrine that is more cloudy*Please selectYesNoAt least one YES to Authorize. Cynergy WILL NOT authorize the testNew discharge from the vagina*Please selectYesNoAn STI panel is required for this test. Unfortunately, you are not currently authorized to proceed with the purchase of this test. If you have any questions or concerns, please don’t hesitate to contact us for further assistance.New discharge from the penisPlease selectYesNoAn STI panel is required for this test. Unfortunately, you are not currently authorized to proceed with the purchase of this test. If you have any questions or concerns, please don’t hesitate to contact us for further assistance.2. Do you have any of the following symptoms?New pain in lower back*Please selectYesNoIn Person Evaluation RecommendedNausea*Please selectYesNoIn Person Evaluation RecommendedVomitting*Please selectYesNoIn Person Evaluation RecommendedFever*Please selectYesNoIn Person Evaluation RecommendedShivering*Please selectYesNoIn Person Evaluation RecommendedAt least one YES to Authorize. Cynergy WILL NOT authorize the testOther symptomsPlease selectYesNoPlease explain3. Are you a female of child bearing age (18-44)?*Please selectYesNoHave you had a hysterectomy?*Please selectYesNoWould you consider undergoing a pregnancy test?*Please selectYesNoAs you have chosen to decline the pregnancy test, we are unable to proceed with the test at this time. Should you change your mind or require further assistance, please feel free to let us know.4. How long have you had these symptoms?: (Check one).* Less than 3 days 3 days to 1 week 1-2 weeks More than 2 weeks 5. What have you done to manage your symptoms?: (Check all that apply)* Painkillers Antibiotics Cranberry products Drinking more fluids Other remedies None Painkillers – Which one?*Antibiotics: Which one(s) ?*6. Have you had a Urinary tract infection (UTI) before, these are sometime called a bladder or water infection?:* Yes – In the previous 6 months Yes – In the previous year Yes – More than 1 year ago No If Yes How many ?*7. 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) : (Check one)* Yes No Unfortunately, you are not currently authorized to proceed with the purchase of this test. If you have any questions or concerns, please don’t hesitate to contact us for further assistance.8. Any other important medical history associated with urinary tract issues? (Answer None or Please explain):* Yes None Please explain medical history associated with urinary tract issues*This form will be given to the ordering physician to evaluate your symptoms prior to an order being given for a RTL UTI test.
