UTI Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *Phone *Marital status MarriedSingleWidowDivorcedSeparatedDo you feel any kind of pain?Before Urination After UrinationDo you feel any kind of burning? Before Urination After UrinationDo you notice any blood in urine? YesNoDo you notice any pus in urine? YesNoDo you notice any abnormal discharge urine? YesNoDo you notice any kind of swelling around vulva? YesNoDo you experience any kind of Itching around vulva? YesNoAll the complaints increase after intercourse? YesNoMostly my UTI happen?Before Urination After UrinationDo not applyHow often you have UTI s in past 6 months? Only once 2-3 times more than 3 timesWhat was your usual duration of infection without any treatment? 1-3 days 3-7 daysMore than 7 days. 13. What was your usual duration of infection with any treatment? 1-3 days 3-7 daysMore than 7 days. Are you using any contraceptive devices? YesNoIf yes, since how long? Are you using any lubricating jelly? YesNoIf yes, since how long? Does your husband use condoms? YesNoIf yes, which one? LatexRubberAre you a Vegetarian Non VegetarianWhich types of food do you like? Spicy Mild Do you have any Gastric Problem?YesNo Are you suffering from blood pressure. If so, whether it is? High LowDo you sleep well?NoYesHow many times you wake up to urinate during night? I don’t wake up.1-3 times. 4-6 times. More than 6 timesDo you exercise dailyNoYesYour partner has any sexual problem? NoYesHave you ever been treated in past? NoYesIf so detailsHave you ever had kidney infection?NoYesHave you ever had kidney pain? NoYesWhat are your expectations from our treatment? I don’t expect good resultsI expect good results.I would be happy if I improve. I am confidentAre you willing to make changes to your life style or diet modifications? I can not change my lifestyleI have tried nothing works for meI am willing to change my lifestyle if neededI am willing to do what ever is needed to get best resultsPhoneSubmit