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Format: 07000000000.
- Date of birth*
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- Sex*
- Sex (for pregnancy letter requests) - hidden*
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- Do you have any pre-existing health conditions your Partner Practitioner should be aware of?*
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- Are you taking any medications regularly?*
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- How far can you walk before you have to stop to catch your breath?*
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- Are you currently suffering from any infectious diseases?*
- Are you presently sick due to any infections?*
- Did you ever have any infectious diseases in the past that necessitated isolation?*
- Have you previously been diagnosed with Tuberculosis?*
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- When is your estimated delivery date?*
- Is your pregnancy single or multiple?*
- Did conception occur naturally or with the assistance of medical procedures (e.g., IVF, fertility treatments)?*
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- Have you experienced any complications or adverse events during your current pregnancy?*
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- Do you have a history of any of the following medical conditions?*
- Please confirm that your midwife does not advise against flying*
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- Are you currently on any prescribed medications?*
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- What was your Body Mass Index (BMI) at the onset of your pregnancy?*
- What was your latest antenatal clinic blood pressure reading?*
- When was your most recent blood pressure reading taken?*
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- Main reason for travel or holiday cancellation*
- Start date of symptoms*
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- Main reason for medical letter*
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- Have you sought medical care from your GP or local A&E for your medical issue?*
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- Can you confirm that over the last 48 hours, no new spots have appeared, and that all the chickenpox spots have now scabbed over?*
- Have you had any fever within the last 48 hours?*
- Have you been in contact with anyone with Monkeypox?*
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- Valid from*
- Valid to (inclusive)
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- Flight Date
- Outbound flight date*
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- What is the duration of your flight?*
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- Do you have a return flight?*
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- Return flight date*
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- Should be Empty: