Form - UTI Cefuroxime – DIMA Health Technology Inc.

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You're only a few questions away from UTI relief!

Please fill this questionnaire to complete your order.

Please enter your first name:

Please enter your last name:

Please enter your email:

What was your sex assigned at birth?

Male

Female

How old are you?

Does it hurt when you urinate?

Yes

Does it feel like you need to urinate even after you have just recently urinated?

Yes

Do you have pain in your abdomen/lower stomach area?

Yes

Do you have pain in your back or on your sides below your ribs?

Yes

Have you taken any antibiotics in the last two weeks? If you have, please list them down.

Have you been diagnosed with a UTI in the last three months?

Yes

Please list down any known allergies.

Please list down any medication you are currently taking.

Please check any of the following that applies to you.

We cannot prescribe this medicine to you if any of the following apply to you. Instead, we recommend going to the hospital.

Blood in your urine

Persistent vomiting

A fever with accompanying chills

Severe abdominal pain

None of the above

Please list down any known medical conditions.

Are you pregnant?

If you are unsure, please purchase a pregnancy test (available in our shop page) to confirm.

Yes

Thank you for filling the form!

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