Disclaimer - Malaria Consultation Form

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

Have you checked the NHS Fit To Travel website and confirmed that this treatment is recommended for the place you are visiting?

What is your gender?

What is your Date of Birth?

Day

Month

Year

Have you been diagnosed with any medical conditions? Yes | No

If Yes Give Details

Have you ever been diagnosed with a mental health illness? Yes | No

If Yes Give Details

Have you had any Malaria treatment before? Yes | No

If Yes Please state which medication you have had.

Have you had an allergies or side effects to any of the following (anti-malarials): Atovaquone or proguanil chloride (Malarone) Doxycycline Mefloquine (Lariam) Quinine or Quinidine Chloroquine Any antibiotics Any other allergy

Please provide more information if you have any other allergies

Who is this medication for? (If you are requesting for multiple people, please tell us about everyone)

Have you ever been diagnosed with malaria?

Kidney disesase Liver disease Cancer or any previous cancer diagnosis Spleen removal Mental health conditions (including depression or anxiety) Epilepsy or convulsions Myasthenia gravis, a condition characterised by muscle weakness, difficulty chewing.

Please specify what condition you suffer from:

How long is your trip? Answer in days please.

Which month and year are you travelling?

List all of the countries that you plan to visit in your upcoming trip and include how many days you are in each place please.

Are you currently taking any prescription medication, over the counter, medication, recreational drugs or herbal medication?

Are you taking any of the following medications? Medicines for blood clotting disorders or blood thinners. eg. warfarin Diabetic medication Mental or psychiatric disorder medication Epilepsy medication eg.sodium valproate, carbamazepine, phenobarbital.

Please specify any other medication

Please provide any further information that you think will help our prescriber when reviewing this request for medication. (optional)

No malaria tablet provides 100% protection. Do you understand this?

Have you checked the NHS Fit To Travel website and confirmed that this treatment is recommended for the place you are visiting?

If you experience any flu-like symptoms after returning from your trip for up to a year after you return, you should seek immediate medical attention and inform the doctor about your background and recent travel history to a malarial zone. Do you understa

I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform my own regular doctor of

Would you like us to inform your GP?

To continue, please provide your GP's surgery address below.

Product

Atovaquone with Proguanil Tablets£23.99