Malaria tablets

Malaria tablets

Dates of Trip

Date of departure

Return date or overall length

Itinerary and purpose of visit

Coutry to be visited

Mode of Transport

Length of Stay

Remote? Trek? Medical access? Altitude?

Personal Medical History

Do you have any recent or past medical history of note? *

Details (to be reconfirmed at each appointment) *

Do you take any current or repeat medicines? *

Details (to be reconfirmed at each appointment) *

Do you have any allergies to any medicines? *

Details (to be reconfirmed at each appointment) *

Have you had a serious reaction to any antimalarial or doxycycline before? *

Details (to be reconfirmed at each appointment) *

Do you known if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients? *

Details (to be reconfirmed at each appointment) *

Do you suffer from any blood disorders such as thalassaemia or sickle cell anaemia? *

Details (to be reconfirmed at each appointment) *

Do you have a past history of black water fever? *

Details (to be reconfirmed at each appointment) *

Do you have severe impairment of liver or kidney function? *

Details (to be reconfirmed at each appointment) *

Are you taking halofantrine? *

Details (to be reconfirmed at each appointment) *

Do you currently suffer or have suffered, at any time from depression, generalised anxiety disorder, psychosis, schizophrenia, suicide attempts, suicidal thoughts, self-endangering behaviour or and other psychiatric disorder, epilepsy or convulsions of any origin? *

Details (to be reconfirmed at each appointment) *

Women Only

Are you pregnant or planning a pregnancy? *

Details (to be reconfirmed at each appointment) *

Are you breastfeeding? *

Details (to be reconfirmed at each appointment) *

Write below any further information which may be relevant e.g. medicines taking, conditions, concerns...

Patient's Personal Details

Title

First Name

Last Name

Telephone

Gender

Date of birth

Patient Address

NHS No. (If Known)

GP Name and Address

GP Telephone (If Known)

Would you like us to send a copy of this consultation to your GP?

Product total

Options total

Grand total

£666.00

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020 8616 2700

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