Travel Sickness Assessment | Pharma Aesthetics

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Travel Sickness Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Travel Sickness Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Do you often experience nausea or vomiting when travelling by car, boat, or plane?Do you often experience nausea or vomiting when travelling by car, boat, or plane?*

Yes

No

Please provide more information below.*

Have you suffered from dizziness or a sensation of spinning (vertigo) during travel?*

Yes

No

Please provide more information below.*

Do you frequently experience headaches or migraines associated with motion sickness?*

Yes

No

Please provide more information below.*

Are you prone to sweating or feeling unusually cold during journeys?*

Yes

No

Please provide more information below.*

Do you get a feeling of uneasiness or general discomfort when reading or looking at a screen while travelling?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medication that could potentially interact with travel sickness treatments?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies to medications commonly used to treat travel sickness, such as antihistamines or hyoscine?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant or breastfeeding, as this may influence the choice of travel sickness medication recommended to you?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any pre-existing medical conditions, such as glaucoma, kidney disease, or epilepsy, that could affect the suitability of certain travel sickness treatments?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously tried any travel sickness remedies or medications that were ineffective or caused adverse reactions?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions are designed to provide a comprehensive overview of the patient's condition and any factors that may influence the selection and efficacy of travel sickness treatments offered.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Comments

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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