Name
*
First Name
Last Name
DOB:
*
Email
Mobile Number:
What is your postal address?
What is your height?
What is your weight?
What date are you leaving for your travels?
How many days will you spend in the Malaria risk area?
Have you recently travelled to a Malaria risk area (within the last 6 months?)
What is the reason for you trip?
Where will you be staying?
Will you have access to appropriate medical care?
Are you pregnant, breastfeeding, planning a pregnancy or at risk of pregnancy whilst taking this medication?
Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period.
Do you have or have you ever had any of the following medical conditions?
- Depression, thoughts of suicide or self-endangering behaviour
- Any other mental health issue, such as anxiety, schizophrenia, paranoia or psychosis
- Hallucinations
- Nightmares or abnormal dreams
- Restlessness
- Epilepsy, fits, convulsions or seizures
- Blackwater fever
- Heart problems, especially changes in heart rhythm
- Insomnia
- Liver or kidney problems
- Eye problems
- Blood or lymphatic disorder (increase or decrease in white blood cells, red blood cells or platelets)
- Neuropathy with signs e.g. pins and needles, weakness, numbness, new or worsening clumsiness or unsteadiness on your feet, or shaking of the hands and fingers
- Inflammation of the lungs also known as pneumonitis. This is a serious, potentially life-threatening allergic reaction in the lungs which may cause fever, chills, cough, shortness of breath or chest pain
- Malaria
- Low blood glucose due to a pre-existing condition called congenital hyperinsulinemic hypoglycaemia
- Tuberculosis
- HIV
- Dysfunctional or absent spleen
- A personal or family history of severe mental health disorders
- Psoriasis
Do you have any other medical conditions?
Do you understand that taking antimalaria medicine doesn't guarantee you 100% protection against malaria and it is important to:
- Minimise skin exposure to mosquitos by wearing full length, loose fitting clothing with long sleeves, trousers and socks
- Use insect repellent on exposed areas of the skin
- Sleep in a bed net which has been treated with insecticides
- Use coils or electric vaporisers to deter mosquitos from entering the room
- Use insecticide sprays
- Close windows and doors at sunset, if they are not screened
Do you agree to see a doctor immediately and tell them that you have been in a malaria if you develop the following symptoms whilst travelling or within 1 year of returning from travel?
High temperature (fever)
Sweats and chills
Headaches
Vomiting
Muscle pains
Diarrhoea
Loss of appetite
Sore throat, cough or breathing difficulties
Confusion
Are you aware that...
- You should read the instructions provided with your medication
- It is important to finish the course of tablets upon your return
- There is a possibility that this medication may affect your ability to drive or operate machinery
- It is best to take this medication with food or with a milky drink
For Lariam:
- You should stop taking Lariam and seek medical help immediately if you experience any changes to your mental health, or experience neuropsychiatric symptoms. These may include anxiety disorders, paranoia, depression, hallucinations. If you experience insomnia, abnormal dreams/nightmares, acute anxiety, depression, restlessness or confusion, you should contact your GP for advice
- In a small number of patients it has been shown that dizziness, vertigo and loss of balance may persist for months or longer after stopping Lariam
- If you have been told by your doctor that you have an intolerance to some sugars, such as lactose or galactose, you should not take Lariam
- You should not take Lariam for more than 12 months
- If you need an oral vaccine to help prevent you from catching typhoid, you should take this at least 3 days before you start taking Lariam
- It is not recommended to dive whilst you are using Lariam. If you expect to go diving on your travels, an alternative medication will be necessary
Do you understand that you should stop taking this medication and seek urgent medical advice if you experience:
- Skin rash, which may blister and looks like small targets
- Severe widespread rash with blisters and peeling skin, especially if it occurs around the mouth, nose, eyes and genitals
- Any other signs of an allergic reaction such as itching, rash, wheeze, tightness of the chest/throat, difficulty breathing, low blood pressure, swollen eyelids, face, lips, tongue or other part of the body
- Any other unusual side effect
Is there any questions or further information that you would like to provide?
- You will read the Patient Information Leaflet supplied with your medication
- You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical status changes during treatment.
- You are over 18 and the treatment is solely for your own use
- You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
- You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's
- You will inform your GP that you have ordered this medication
- By continuing, you agree to our Terms & Conditions and Privacy Policy
