Flu Jab Assessment – Workspace Tabi Health

Name

First

Last

Parent/Guardian name if under 18 years old

First

Last

What is your biological sex?

Male
Female

Biological sex is one of the inputs required to determine your eligibility.

Have you had a serious allergic reaction or anaphylaxis reaction to any influenza vaccines in the past?

Have you already received a flu vaccine during this season?

Does any of the following apply to you?

Acutely unwell and/or has a fever (≥38°C), in the last 24 hours
Have an evolving neurological condition
Immunosuppressed due to disease or treatment
Currently receiving salicylate therapy
Have severe asthma or active wheezing. This includes a history of active wheezing in the past 72 hours or those who have increased their use of bronchodilators in the previous 72 hours.
Have received influenza antiviral agents in the last 48 hours.
Have unrepaired craniofacial malformations
Have heavy nasal congestion
None of the above

Do you have thrombocytopenia or any coagulation disorder ( or taking anticoagulants)

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Are you currently breast-feeding?

Are you allergic to latex?

Have experienced a systemic allergic reaction (e.g., anaphylaxis) to eggs or to egg proteins (e.g., ovalbumin).

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. conditions you have previously been treated for)

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What is your age?

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient ID and Consent

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Click to view pharmadoctor terms & conditions

Patient ID and Consent 2

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.
I have read the Pharmadoctor terms and conditions

Patient Name

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction to any acne treatments before?

Do you have any allergies?

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy)

Are you breast feeding?

Have you started puberty?

Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment?

Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea?

Are you currently using any other treatments for acne?

Have you recently received an acne treatment containing antibiotics?

If you have used acne treatments before, did you experience any side effects or skin irritation?

Do you have a history of photo-allergy (skin reactions in the sunlight)?

Do you have, or have you had any of the following? ̵ Regional enteritis (crohn's disease) ̵ Ulcerative colitis (inflamed colon and rectum) ̵ Inflammatory bowel disease or antibiotic-associated colitis (including pseudomembranous colitis)

Have you or any of your close family had skin cancer?

Do you currently have sunburn, broken skin or abraded skin?

Do you have any allergic diseases such as asthma, eczema or rhinitis?

Do you have any liver or kidney problems?

Are you currently using any cosmetics, medicated cleansers or scrubbing solutions?

Do you suffer from severe psychological distress because of your acne?

Have you undergone or recently undergone procedures such as depilation, chemical hair treatments, chemical peels, dermabrasion, laser resurfacing of the skin or phototherapy?

Are you sensitive to sunlight or do you have considerable sun exposure?

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for)

Complete Patient Details

Patients Name

First

Last

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient GP Consent

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent (Other)

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions.

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)

Complete Patient Details

Start Assessment

Complete Patient Details