Clone of FastDoc Medical Questionnaire

Event Name

Event Date

Date

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

Do you have 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

Brief description of your condition and timeline (optional)

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?

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)

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 the fitness to fly assessment and any certificate issued are based solely on the information I have provided at the time of assessment and reflect my condition at that point in time. I acknowledge that the clinician does not assume responsibility for any complications that may occur during or after travel. If any information provided is inaccurate or incomplete, or if my condition changes, the certificate may no longer be valid and I will seek further medical advice before travelling. I understand 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 confirm that I have been advised to take appropriate precautions during air travel, including maintaining hydration, mobilising regularly during the flight, and following any 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?

Prescriber Full Name

Prescriber Professional Registration

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. 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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