Cystitis UTI (MedPro)

Women only: Are you pregnant or is there a possibility you may be pregnant or start breastfeeding while taking this medicaiton?

Are you taking any other medicines?

This could be prescription medication, over the counter or herbal remedies.

Do you suffer from any allergies?
If you do, kindly explain them below

Have you even been reqiured to attend hospital due to cystitis spreading to your kidneys?

Have you ever been diagnosed with the following?

- Any kind of blood disorder (such as porphyria)

- G6PD (glucose-6-phosophate dehydrogenase) deficiency

- Any pulmonary disease

- Any kidney (or having dialysis treatment) or live disease

- Any illness causing severe weakness

- Anaemia and/or a lack of vitamin B or abnormal levels of salts in your blood

- Low potassium level

- Diabetes

- Folic acid deficiency

- Susceptibility to peripheral neuropathy

Are you taking any of the following?

- Antacids for indigestion (e.g. magnesium trisilicate)

- Medication for gout (probenecid or sulfinpyrazone);

- Medication for raised pressure in the eye (acetazolamide);

- Anticoagulants (warfarin);

- Any other antibiotics (quinolones,  rifampicin);

- Any immunosuppresant drugs (prednisolone, azathioprine, leflunomide, methotrexate, Ciclosporin);

- Medicines which make the urine less acidic (e.g. potassium citrate mixture).

- Oral typhoid vaccine or any other vaccine;

- Amiodarone (for irregular heart rhythms)

- Ciclosporin (to prevent rejection after transplantation)

- Digoxin (to treat heart conditions)

- Phenytoin (to treat epilepsy)

- Pyrimethamine (to treat malaria)

Are you aware symptoms should improve within 24hours and resolve within 3 days of strating treatment?

If symptoms do not resolve within 3 days, you should seek medical help from your GP.

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Do you agree to the following ?

- The treatment is solely for your own use.

- You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health.

- You will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. 

- You will inform your doctor about any unusaul side effects.