UTI/ Cystitis – ROD

[text size="3"] yo [select value="female|male"] complains of [checkbox value="dysuria|frequency|urgency|incontinence|hematuria|cloudy urine|fever|chills|vaginal discharge|flank pain"] starting [text size="3"] day(s) ago.

Patient [select value="has not|has"] had a UTI in the past.

Review of systems:
[select value="no|YES"]<-symptoms >7 days duration
[select value="no|YES"]<-shaking chills
[select value="no|YES"]<-flank pain
[select value="no|YES"]<-Suprapubic cramping
[select value="no|YES"]<-Fever [text name="variable_6" default="sample text"]
[select value="no|YES"]<-nausea
[select value="no|YES"]<-vomiting
[select value="no|YES"]<-abdominal pain
[select value="no|YES"]<-change in vaginal discharge or odor
[select value="no|YES|n/a"]<-painful intercourse

Risk factors present: 
[select value="no|YES"]<-Concern about STI's
[select value="no|YES"]<-Frequent UTI's
[select value="no|YES"]<-pyelonephritis within the last 3 months
[select value="no|YES"]<-diabetes
[select value="no|YES"]<-pregnancy [text name="variable_5" default=""]
[select value="no|YES"]<-immunosuppression
[select value="no|YES"]<-kidney stones
[select value="no|YES"]<-kidney failure
[select value="no|YES"]<-antibiotic for a UTI in the last 4 weeks

[checkbox name="variable_2" value="Azo|Hydration|abx"] [text name="variable_6" default=""]