Are you pregnant or breastfeeding?

Have you been diagnosed with liver, kidney, or heart disease?

Are you travelling to Europe, North America, or Australasia?

Are you allergic to azithromycin, erythromycin, or clarithromycin?

Are you aware self-treatment with antibiotics is ONLY suitable for the following people?

• Travellers to remote rural areas, who are distant from medical help.
• Travellers with pre-existing bowel problems such as inflammatory bowel disease where infection may trigger a relapse.
• Travellers with pre-existing medical conditions which may be worsened by severe infection or dehydration, i.e. poorly controlled diabetes, renal impairment etc.
• Travellers with a tendency to severe travellers’ diarrhoea (on the basis of previous travel experience).

Are you taking any of the following medications regularly?

• Ciclosporin – for reducing immunity after transplant
• Digoxin – for irregular heart or heart failure
• Ergotamine – taken rarely for migraine
• Terfenadine – antihistamine for hay fever and allergy
• Theophylline – for asthma used rarely
• Disopyramide – for irregular heart used rarely
• Rifabutin – rarely used antibiotic
• Coumarins – anticoagulant for thinning the blood -includes warfarin
• Avomine or other antisickness tablets containing promethazine – NOT to be taken at the same time as azithromycin

Are you aware traveller’s diarrhoea should start to improve within 24 hours of starting antibiotic?

Do you agree to azithromycin being supplied to you for travellers’ diarrhoea ‘off label’?

If a medicine is used for an off label (unlicensed) purpose the manufacturer is not liable in case of adverse events. The prescribers take the responsibility for the prescribing.

Do you agree to see a doctor if:

• You have a fever.
• You have blood in your stools.
• You are unable to keep fluids or food down.
• You are showing symptoms of dehydration such as not urinating for over 8 hours, dizziness, tiredness, or confusion.
• You passed 8 or more unformed stools in the last 24 hours.
• You have constipation, abdominal pain and vomiting caused by blockage of the bowel.
• Your symptoms get worse during treatment, your symptoms continue despite treatment, or your symptoms re-appear shortly after treatment.

Do all the following apply to you?

• I will read the information leaflet supplied with my tablets
• The medication is for my own use
• I am over 18 and I agree to identity verification checks
• I have completed this questionnaire myself and fully understand all the information
• My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment
• I agree to the terms & conditions, privacy policy, & data sharing policy

What is the name of your GP surgery and do you consent to us contacting them about your treatment?