Q No.QuestionAnswer1Have 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.Please write your explanation in the box below Yes No2Have you ever had an allergy (hypersensitivity) to anti-malarials? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Have you ever been diagnosed with malaria? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Are 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.Please write your explanation in the box below Yes No5Have 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.Please write your explanation in the box below Yes No6Are 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.Please write your explanation in the box below Yes No7Are 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.Please write your explanation in the box below Yes No8Do 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.Please write your explanation in the box below Yes No9What 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.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
