UTI Survey | Form

Instructions The questionnaire consists of 27 questions based on basic personal details, risk factors that may increase susceptibility towards UTI, symptoms and diagnostic results. Please tick the more relevant option.

What is your age? *

0-1212-4040-6060<

What is your sex? *

MaleFemale

What is your marital status? *

SingleMarriedDivorcedWidow/Widower

How much is your daily water intake? *

0-2 liters2-4 liters4-8 litersMore than 8 liters

Are you circumcised? *

YesNo

Are you suffering from prostrate or urinary tract stones? *

YesNo

Did you underwent UTI or urinary tract surgery in past? *

YesNo

Are you suffering from diabetes? *

YesNo

Are you having any spinal cord injuries? *

YesNo

Were you on catheter in past? *

YesNo

Are you using diaphragm or spermicide? *

YesNo

Are you using spermicidal or Unlubricated condoms during intercourse? *

YesNo

Are you suffering/suffered from any Sexually transmitted disease (STD)? *

YesNo

How many times in a week you take coffee? *

Daily3-4 timesmore than once dailyvery rareNever taken

How many times in a week you smoke tobacco? *

Daily3-4 timesmore than once dailyvery rareNever taken

How many times in a week you consume alcohol? *

Daily3-4 timesmore than once dailyvery rareNever taken

Do you need a tube to drain your bladder? *

YesNo

Are you pregnant? *

YesNo

How many times you are urinating in a day? *

0-4 times4-8 times8-16 timesmore than 16 times

Are you facing blocked urine flow? *

YesNo

Do you have problem of Incontinence (not able to control when you urinate)? *

YesNo

Despite strong urge to urinate, you are passing small amount of urine? *

YesNo

Do you have pain in your back or side below the ribs? *

YesNo

Are you having dark, cloudy, bloody or foul-smelling urine? *

YesNo

Do you often feel tired, shaky, weak and having muscle aches? *

YesNo

Are you often suffering from nausea and vomiting? *

YesNo

Are you diagnosed with UTI in past or present? *

YesNo

If yes, what was your type of UTI? If no, please click Healthy. *

HealthyDo not know the typeCystitis (Bladder infection)Pyelonephritis (Kidney infection)Urethritis (Urethra infection)Not Diagnosed

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Urinary Tract Infection (UTI) Survey Form

Basic personal details

Risk factor based questions

Symptoms based questions

Diagnostic resuts

Verification