Anti-Malaria Consultation

Are you aged between 18 and 80 years old? *

Yes No

Are you travelling to a malaria-endemic area? *

Yes No

What is the reason for requesting this treatment?

Have you ever been diagnosed with Malaria *

Yes No

When was you diagnosed with Malaria?

How long are you travelling to a malaria-endemic area for? *

Please answer to the nearest week

Please select your weight? *

Are you allergic to any of the following medications or their ingredients?:

Atovaquone or proguanil chloride (Malarone)
Doxycycline
Mefloquine (Lariam)
Quinine or Quinidine
Chloroquine

*

Yes No

Do you have any other allergies we should be aware of? *

Yes No

Please provide more details on all allergies you have

Regarding your medical conditions, do you currently have or suffer from any of the following? *

You can select multiple options if required

Kidney disease Liver disease Mental health conditions (including depression or anxiety) Epilepsy or convulsions Myasthenia gravis (A condition characterised by muscle weakness, difficulty chewing and swallowing and slurred speech) Systemic lupus erythematosus (SLE) Porphyria (a genetic disorder of the blood) Blackwater fever Any serious medical condition which may require immediate hospitalisation None of the above

Are you currently taking or have recently finished taking (in the last month) any medication, whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide an update list of all medications whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs that you are taking or have recently stopped taking

Are you breastfeeding, pregnant, or possibly pregnant? *

If you are Male, please select No

Yes No

Is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

Before you continue

Please read the following statements:

I confirm these questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from Pharmacy
I confirm I will take the medication as prescribed or directed for its intended use and if I am not requesting the starting dose for that medication, I have taken the medication previously on that dose and without any side effects
I have read or will read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
I confirm that if I experience any flu-like symptoms after returning from my trip for up to a year after returning, and particular within 3 months of return, I will seek immediate medical attention and inform the Doctor/medical team of my recent travel background & history
I understand it is important to avoid mosquito bites and to take this prophylaxis treatment regularly

I agree to all of the above statements