Consultation

About You

Please confirm that you are aged between 18 and 80 years.

Yes

No

We are unable to supply you with treatment if . Please consult your GP for more information.

Your Health

Do you have any allergies to any of the following medications?

• Atovaquone/Proguanil (Malarone)

• Doxycycline

• Mefloquine (Lariam)

• Quinine or Quinidine

• Chloroquine

• Any antibiotics

Yes

No

We are unable to supply you with treatment if . Please consult your GP for more information.

Are you pregnant, breastfeeding, planning a pregnancy, or planning to breastfeed?

Yes

No

We are unable to supply you with anti-malaria medication. Please consult your GP.

Is Malarone suitable for everyone?

No. Malarone (atovaquone/proguanil) is not suitable for everyone. It may not be appropriate for people who:

•. Are allergic to atovaquone, proguanil, or any of the ingredients in Malarone.

•. Have severe kidney disease.

•. Are pregnant, breastfeeding, or planning a pregnancy (unless advised by a healthcare professional).

• Are taking certain medications that may interact with Malarone.

A medical assessment is required to determine whether Malarone is a suitable option for you.

Yes

No

We are unable to supply you with treatment if . Please consult your GP for more information.

Have you ever been diagnosed with any of the following medical conditions?

• Kidney disease

• Liver disease

• Mental health conditions (such as depression or anxiety)

• Epilepsy or seizures (convulsions)

• Myasthenia gravis (muscle weakness causing difficulty chewing, swallowing, or speaking)

• Systemic lupus erythematosus (SLE)

• Porphyria (a genetic blood disorder)

• Blackwater fever

Any serious medical condition that may require urgent hospital treatment

Yes

No

We are unable to supply you with anti-malaria medication. Please consult your GP.

Have you previously been diagnosed with malaria infection?

Yes

No

We are unable to supply you with anti-malaria medication. Please consult your GP.

Your Medication

Are you currently using any of the medications listed below?

• Medicines for blood clotting disorders or diabetes (e.g. warfarin)

• Medicines for psychiatric or mental health conditions

• Anti-epileptic medicines (e.g. sodium valproate, carbamazepine, phenobarbital, phenytoin)

• Medicines for heart conditions or high blood pressure (e.g. quinapril)

• Antibiotics (e.g. tetracycline, rifampicin, rifabutin, penicillins, cephalosporins)

• Antihistamines for allergies

• HIV medications such as efavirenz or protease inhibitors

• Halofantrine

• Tramadol (for severe pain)

• Ketoconazole (for fungal infections)

• Metoclopramide (for nausea and vomiting)

• Etoposide (for cancer treatment)

• Antacids containing aluminium, calcium, or magnesium, or supplements containing iron, bismuth, or zinc

• Ciclosporin (used after organ transplant to suppress the immune system)

Yes

No

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

Agreement

Do you consent to the following conditions?

• You agree to read the patient information leaflet provided with your medication.

• You agree to notify us and your GP if you experience any side effects, begin any new medicines, or if your health condition changes during treatment.

• You confirm that the treatment is intended for your personal use only.

• You confirm that the information you have provided is complete, accurate, and truthful.

• You understand that the prescriber relies on your responses when making prescribing decisions, and providing incorrect information may be unsafe.

• You acknowledge that treatment decisions are made in consultation with you, but the final decision to prescribe rests with the prescriber.

Yes

No

You must agree to this before continuing. If you need assistance contact our customer support.

Do you understand that if you develop flu-like symptoms at any time within one year after returning from your trip, you should seek urgent medical care and inform the doctor about your recent travel history?

Yes

No

Please read the anti-malaria information page again and confirm this statement.

Have you checked the NHS Fit for Travel website to confirm that the selected malaria tablets are appropriate for the countries you plan to visit?

Yes

No

Visit www.fitfortravel.nhs.uk to ensure the malaria treatment is suitable for your destination

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Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

About You

Your Health

Your Medication

Agreement

Complete our 2 minute questionnaire

Yasmeen Akthar

Mr. Saleh Ahmed

Mr. Mohammed Shajan Ali

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01604345869

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