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HW+ Health and Wellbeing Plus | Canterbury Clinic

Health & Wellbeing Plus

Your One Stop PAYG
Health & Wellbeing Clinic

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info@hwplus.co.uk

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HW+ Health and Wellbeing Plus | Travel Vaccines

Medical Assessment

This form is a requirement for any medical procedure undertaken

Please complete this online form before your booked appointment

Our nurse practitioner will go through this form with you at your initial consultation before proceeding with any medical service required

Medical Assessment Form

Personal Details

First name*

Last name*

Date of Birth*

Phone*

Sex*

Male

Female

Other

Email*

Address (including Postcode)*

Please provide your preferred pharmacy (if applicable, prescriptions will be sent electronically)*

Medical History

Do you have or have you ever had any of the following? Tick all that apply

Heart Disease

Lung Disease or Astham

Kidney or Liver Disease

Diabetes

Bleeding/Clotting Disorders

Weekened Immune System (e.g. HIV, chemotherapy radiotherapy, immunosuppresive medication

Seizures or Neurological Conditions

Anxiety/Fear of Needles

History of severed Allergies or Anaphylaxis

Any other conditions or surgeries not listed

If YES to any of the above please provide details

Do you have any known allergies? e.g. latex, eggs, antibiotics

Yes

List Allergies

Are you currently pregnant or breastfeeding?*

Yes

N/A

Are you currently taking any medications (including steroids, immunosuppressants, anticoagulants, or herbal remedies)?*

Yes

Have you ever had a serious reaction to a vaccine?

Yes

Vaccine Reaction

Health & Wellbeing Plus

info@hwplus.co.uk

31 Saint George's Place

Canterbury

CT1 1UT

Email our Reception Team

First name*

Last name*

Email*

Message*

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