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  1. Home
  2. Malaria
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1. Assessment Form
2. Choose Treatment
3. Your Order
4. Finish

Medical Assesment Malaria

About You

Are you registered with a GP practice in the UK?

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Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

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Do you believe you have the capacity to make decisions about your own healthcare?

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You must have the capacity to make decisions about your own healthcare to proceed. Please see your GP
Symtoms

Please can you tell us which country you are visiting? If the country is not on the list, then this antimalarial tablet is not recommended

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If more than one country please use the box below to provide additional information. (including how many days you are in each place)

To help us assess your risk of malaria, could you let us know if your trip involves any of the following (please tick all that apply):





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Which month(s) of the year will you be in this country?












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Have you checked the NHS fit to travel website and confirmed that this treatment is recommended for the place you are visiting?

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What date will you be arriving in a malarial zone?

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Health

Are you allergic to any of the following:

  • Atovaquone or proguanil chloride (Malarone)
  • Doxycycline
  • Mefloquine (Lariam)
  • Quinine or Quinidine
  • Chloroquine
  • Any antibiotics
This field is required.
This medication is unsuitable for you. Please consult your GP.

Are you currently pregnant or breast feeding?

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This medication is unsuitable for you. Please consult your GP.

Have you been diagnosed with any of the following?

  • Kidney disesase
  • 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
This field is required.

Have you ever been diagnosed with malaria?

This field is required.

Do you agree to see a doctor immediately and tell them that you have been in a malaria risk area if you develop the following symptoms whilst travelling or  within 1 year  of returning from travel?

  • High temperature (fever)
  • Sweats and chills
  • Headaches
  • Vomiting
  • Muscle pains
  • Diarrhoea
This field is required.
Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

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Agreement
  • I confirm I am over 18 years old.
  • The medicine ordered is for my sole use only.
  • I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
  • You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.
This field is required.
You must click on the terms and conditions to continue
The decision about the treatment offered is for both the prescriber and patient to jointly consider. However, the final decision will always lie with the prescriber which will ensure patient safety is not compromised. If treatment is refused, you will be signposted to another service and given a full refund.