Were you assigned female at birth?

Are you between the ages of 18 and 65?

Are you pregnant or breastfeeding?

If you are having periods, have you missed your last one?

Have you developed a new vaginal discharge in the last week?

Do you have a catheter ( a thin plastic tube) inserted into the bladder?

Has your infection followed an operation or other surgical procedure?

Have you had antibiotics for a urine infection in the last six months?

I understand that urinary tract symptoms can settle without antibiotics and I should wait for 48 hours after my symptoms have started before starting antibiotics.

I will seek medical advice from my GP or 111 if:

My symptoms do not improve within 48 hours of starting antibiotics My symptoms are worsening despite having started antibiotics I am unwell, for example I have a high fever, vomiting, back pain

I will seek medical advice from my GP or 111 if my symptoms return on finishing a course of antibiotic

I understand that to help my symptoms, I need to ensure I am drinking water to avoid dehydration

I can take paracetamol or ibuprofen to help with discomfort should I need it.

Do you agree to the following?

You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. The treatment is solely for your own use You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Do you have any of the following conditions?

Acute porphyria Kidney Disease Liver Disease Pulmonary Fibrosis Peripheral Neuropathy Glucose-6-Phosphate Deficiency

Have you had an allergic reaction to Nitrofurantoin?

Are you taking either of the following medications?

Dapsone Prilocaine

Do you have at least two of the following symptoms?

Discomfort, stinging or burning when you pass urine Cloudy urine An increase in the number of times you need to pass urine at night?

Have you seen blood when you have been for a pee?

Do you have any of the following symptoms?

Back pain Temperature above 38degC Feeling very unwell Nausea and vomiting