CARY ADULT MEDICINE

Please complete this e-visit form if you feel you have a bladder or urinary tract infection

Name * Date of Birth * What type of insurance do you have? Have you completed an E-Visit in the past 6 months? Approx. Date of last office visit Are you allergic to any of the following When Did your symptoms start? Do you have burning with urination? Are you urinating more frequently than usual Does your back hurt around your kidneys? Do you feel like you can not completely empty your bladder? Have you had any fever? Have you taken any medications prescription or over the counter If yes which ones? Do you have any abdominal pain ? When was your last urinary tract infection How Many Urinary Tract Infections have you had in the past 6 months Have you notice blood in the urine? Have you tried drinking more fluids or cranberry juice? Do you have a history of Kidney Stones? Have you felt nauseous or thrown-up Please tell us anything else about your symptoms Preferred Contact Method Preferred Contact Number or Email