UTI history

Patient complains of [checkbox value="dysuria|frequency|urgency|dysuria|incontinence|hematuria|cloudy urine|fever|chills|vaginal discharge|flank pain"]
Patient [select value="has|has not"] had UTI in the past.
Pertinent symptoms:
[select value="no|YES"] <-- symptoms > 7 days duration
[select value="no|YES"] <-- shaking chills
[select value="no|YES"] <-- flank pain
[select value="no|YES"] <-- temp > 101
[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"] <-- painful intercourse
Pertinent risk factors:
[select value="no|YES"] <-- pyelonephritis within the last 3 months
[select value="no|YES"] <-- diabetes
[select value="no|YES"] <-- pregnancy, LMP [text]
[select value="no|YES"] <-- immunosuppression
[select value="no|YES"] <-- kidney stones
[select value="no|YES"] <-- kidney failure
[select value="no|YES"] <-- catheterization within the last 2 weeks
[select value="no|YES"] <-- hospitalization or nursing home residency within the last 2 weeks
[select value="no|YES"] <-- 4 or more UTIs within the last 12 months
[select value="no|YES"] <-- failure of antibiotic failure for a UTI in the last 4 weeks