Dickinson college student health services

Dickinson
College
Student
Health
Services
UTI/GU

Name ____________________________________________Class_________Date ____/____/____
S: cc:_____________________________________________________________________________________
Symptoms yes no duration / location / character
Additional Hx. _________________________________________________________________________________________ ______________________________________________________________________________________________________ PMH
Current meds? _____________________________________________________________________________________ Med. allergies?_______________________________________________________________________________________ O: temp___
Dickinson College Student Health Services
UTI/GU (pg 2)
Name ________________________________________________________________________________ Class__________
LABS:
Dipstix
Micro
KOH/WP
ˆ Pyelonephritis ˆ Other ____________________________________________ ˆ Bactrim DS 1 po BID X 3 days / 10 days ˆ Amoxicillin 250 mg 1 po TID X 10 days ˆ Cephalexin (Keflex) 250mg QID / 500 mg BID X 10 days ˆ Referral ______________________________________________________________________________
ˆ LABS REFERRED: ˆ None ˆ UA Culture ˆ Pap ˆ Chlamydia ˆ Herpes ˆ GC
ˆPatient Discharge Instructions Given Health Education
ˆ Warned of possible effects of antibiotics on oral contraceptives
ˆ Instructions: inc.fluids, void p intercourse, hygiene, UTI handout
ˆ RTC __________________________ ˆ RTC PRN
_____________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ \FORM\uti.cck

Source: https://webmail.dickinson.edu/departments/health/Clinical-Checksheets/UTI-CCK.pdf