| 1 | Have you checked on the fitfortravel website to ensure the malaria tablets you have chosen are recommended for the countries you are travelling to?
You must answer this question. You must answer this question. | |
| 2 | Have you ever had an allergy (hypersensitivity) to anti-malarials?
You must answer this question. You must answer this question. | |
| 3 | Have you ever been diagnosed with malaria?
You must answer this question. You must answer this question. | |
| 4 | Are you pregnant or breast feeding or intending to become pregnant or start breast feeding within the next 6 months?
You must answer this question. You must answer this question. | |
| 5 | Have you been diagnosed with any of the following?
• Depression or psychiatric disorders
• Epilepsy or Convulsions
• Liver disease
• Kidney disesase
• SLE, Myasthenia Gravis or galactose intolerance
You must answer this question. You must answer this question. | |
| 6 | Are you taking any of the following medication?
• Anti-coagulant medications (e.g. warfarin)
• Metoclopramide
• Etoposide (a cancer drug)
• Rifampicin
• Rifabutin
• Tetracyclines
• Valproate
• Barbiturates
• Carbamazapine
• Phenytoin
• Ciclosporin
• Ketoconazole
You must answer this question. You must answer this question. | |
| 7 | Are you aware that if you experience any flu-like symptoms after returning you should seek immediate medical attention and tell the doctor about your background and recent travel history?
You must answer this question. You must answer this question. | |
| 8 | Do you agree to the following?
• You will seek medical attention if you experience any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
You must answer this question. You must answer this question. | |
| 9 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
You must answer this question. You must answer this question. | |
