Clone of FastDoc Medical Questionnaire

Event Name

Event Date

Date

Please provide details of the letter you require and the details supporting this:

Any relevant pre-existing health conditions, or taking regular medication?

Please provide details of relevant pre-existing health conditions or medications

Main symptoms (select all that apply)

Date symptoms started

Date

When did the first chickenpox spots appear?

Date

Are ALL spots completely scabbed over now?

Any new spots appearing in the last 24 hours?

When did the last new spot appear?

Date

Does the patient have a fever or feel unwell right now?

Please describe why you need a fit to fly letter

For example: for chickenpox recovery, or due to a recent injury.

Upload a photo of the spots (optional)

Brief description of your condition and timeline

Would you like specific symptoms included in the letter?

When do you want the letter to start from?

Date

Backdated (Days)

When do you want the letter to be valid until? (Inclusive)

Date

Letter Duration (Days)

Name of your Workplace (Optional)

Work Activities

Other

Describe the work adjustments and timeline

Name of school / college / university

What is this sick note for?

Name of gym / fitness provider

What would you like to request?

End date of your membership freeze

Date

Start date of symptoms or condition

Date

Please describe your health condition and how it affects your ability to exercise or attend the gym

Are you currently receiving treatment or taking medication for this condition?

Please provide brief details of treatment or medication

What is the primary reason you're not able to travel?

Please provide further details about why you're unable to travel

Are you having a single or multiple pregnancy?

Estimated Due Date

Date

Have you experienced any complications in this or any previous pregnancies? (e.g. pre eclampsia, bleeding, gestational diabetes, preterm labour, blood clots)

Please provide details of any complications and your current treatment plan if relevant

Please provide details of any complications and your current treatment plan

Have you been diagnosed with high blood pressure during this pregnancy?

Provide details of your last blood pressure reading and management plan

Do you have any significant breathing or oxygen-related issues? (e.g. poorly controlled asthma, chronic lung disease, breathlessness at rest, or problems with low oxygen levels/hypoxia)?

Has your midwife, obstetrics team or any other healthcare professional advised you against flying?

Which airline(s) are you travelling with?

Date of Outbound Travel

Date

Date of Return Travel (Optional)

Date

Your Gestation (Weeks) at date of your outbound flight:

Return Travel Gestation (Weeks)

Flight duration

Upload Pregnancy Care Summary (Optional)

Would you like the airline specific fit-to-fly form to be completed?

Note: Choose Premium Service at checkout for airline specific forms.

Fit to Fly Acknowledgment:

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that this assessment and any subsequent certificate are based solely on the clinical information provided at the time of review and reflect my health status at that specific point in time. I acknowledge that air travel during pregnancy carries inherent risks and that I am responsible for ensuring I remain fit to travel at the time of my flight. I understand that the issuing clinician does not assume responsibility for any complications that may occur during or after travel. Furthermore, I recognise that if my condition changes or if any information provided is inaccurate, this certificate may no longer be valid, and I must seek further medical advice before proceeding. I understand that it is my responsibility to verify my specific airline’s pregnancy and travel documentation policies. This includes ensuring that the date of my medical certificate aligns with the airline's validity window for both my outbound and return journeys. I confirm I have been advised to take necessary precautions during travel, including maintaining hydration, mobilizing regularly throughout the flight, and adhering to all medical advice provided to me.

Please briefly describe your health condition(s) for which you've been prescribed medication.

How many medication are you traveling with?

Please list the medications and quantities that you will be travelling with

Prescriber Full Name (if known)

Prescriber Professional Registration (if known)

Upload Prescription(s)

Risk

Upload Supporting Evidence (optional)

Terms Acknowledgment

I agree to the FastDoc Terms of Service and Privacy Policy. The information I have provided is true and complete to the best of my knowledge. I consent to FastDoc processing my personal and health data to assess my request, generate a certificate, and communicate with me. I understand my request will be reviewed using secure digital systems and assessed by a GMC approved medical practioner. I understand that submission does not guarantee approval and all certificates are subject to clinical judgement including duration of the medical letter. I understand that FastDoc is not an emergency service. If I have urgent or life-threatening symptoms (such as chest pain, breathing difficulty, severe bleeding, stroke symptoms or suicidal thoughts), I will call 999 or attend A&E. For urgent non-emergency concerns, I will contact NHS 111 or my GP. If my symptoms persist or worsen, then I'm advised to seek further medical advice from my General Practitioner. *

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Name of person who referred you

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Error: Please choose Premium Service at checkout as you have requested the airline specific fit to fly form.

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