1. Have you read information about your symptoms on Patient.info?It is advised that you read up about this condition and the related symptoms. |
Yes
No
|
2. Are you allergic to any of the following:- Chloroquine
- Proguanil (Paludrine)
- Chloroquine/proguanil
- Mefloquine (Lariam)
- Doxycycline or Tetracycline
- Atovaquone/proguanil (Malarone or non-branded)
- Quinine
|
Yes
No
|
3. Where are you travelling to? |
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4. Date of travel? |
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5. What is the duration of your travel in days? |
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6. Will you be visiting the following areas? |
Jungle Areas
Rural Areas
High Risk Areas
None Of The Above
|
7. Are you pregnant or do you intend to become pregnant during your trip or within 3 months afterwards?We are unable to prescribe mefloquine (Lariam), doxycycline or atovaquone/proguanil (Malarone or non-branded). You will not be able to order these medications at the end of the consultation. Please continue. |
Yes
No
|
8. Are you breast-feeding or will you be during your trip?We are unable to prescribe mefloquine (Lariam), doxycycline or atovaquone/proguanil (Malarone or non-branded). You will not be able to order these medications at the end of the consultation. Please continue. |
Yes
No
|
9. Have you been diagnosed with liver disease?We are unable to prescribe doxycycline, chloroquine, mefloquine (Lariam), chloroquine/proguanil. You will not be able to order these medications at the end of the consultation. Please continue. |
Yes
No
|
10. Have you been diagnosed with kidney disease?- Not including occasional urinary infection.
We are unable to prescribe chloroquine/proguanil, chloroquine, proguanil, mefloquine (Lariam) or atovaquone/proguanil (Malarone or non-branded). You will not be able to order thes medications at the end of the consultation. Please continue. |
Yes
No
|
11. Do you have epilepsy or seizures?We are unable to prescribe chloroquine/proguanil, chloroquine or mefloquine (Lariam). You will not be able to order these medications at the end of the consultation. Please continue. |
Yes
No
|
12. Are you taking the anticoagulant warfarin (Used to thin the blood)?We are unable to prescribe chloroquine/proguanil, doxycycline, proguanil or atovaquone/proguanil (Malarone). You will not be able to order those medications at the end of the consultation. Please continue. |
Yes
No
|
13. Are you aware that no malaria tablet provides 100% protection?No malaria tablet provides 100% protection. Please change your answer and continue. |
Yes
No
|
14. Are you aware that if you get a fever between 1-week and 1-year after exposure you should seek medical attention and tell the doctor the background?If you get a fever between 1 week and 1 year after exposure you should seek medical attention and tell the doctor the background. Please change your answer and continue. |
Yes
No
|
15. Which travel vaccinations have you had in the last 10 years: |
Hepatitis A
Hepatitis B
Typhoid
Yellow Fever
Rabies
Diptheria/ Tetanus/ IPV
Meningitis ACWY
Japanese Encephalitis
Cholera
Tickborne Encephalitis
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16. Do all the following apply to you?- I will read the patient information leaflet supplied with my tablets.
- The tablets are for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
- I am over 18.
The conditions must apply for you to be able to use this service. |
Yes
No
|
