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Get help for a long term urine problem

Get help for a long term urine problem
Required fields are labelled
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

About the Patient’s Problem

What is your sex at birth?
If you’re not sure, it’s helpful to tell us whether it’s been days, weeks, months or years.

Assessing the type of urine problem

Symptoms of possible cancer

Symptoms

Do you pass small trickles of pee very often? Required
Have you had any blood in your pee? Required

Symptoms of a neurological cause

Symptoms

Please let us know if you have any of the following symptoms:

Severe back pain Required
Leg pain Required
Numbness or tingling in a leg Required
Numbness or tingling around your genitals or buttocks Required
Weak legs Required

Assessing the cause

Caffeine can make your bladder over-active. Caffeine is found in coffee, tea, cola and energy drinks

How many drinks containing caffeine do you have in a usual day?

Alcohol often causes problems with passing urine

Do you drink alcohol?

File Upload

Please attach a photograph or scan of your bladder diary. You can also send photos if you think a photo would help our clinicians.

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.

Communication Preferences

How would you like us to deal with the problem? Required
Video Consultation

Video consultations require you to have a smartphone, tablet, laptop or any computer with camera and microphone or headset. You will also require access to the internet, preferably over WiFi. If the practice decides on a video consultation you will be sent an email containing a link for the video consultation, so it’s best if you can receive your emails on that same device.

If the practice has a mobile number for you, we may send text messages to this number to inform you of an appointment time, or to allow you to book an appointment at a time of your choice.

Terms & Conditions Required