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2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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Travel / Malaria Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Are you allergic to any of the following:

    • Chloroquine
    • Proguanil (Paludrine)
    • Chloroquine/proguanil
    • Mefloquine (Lariam)
    • Doxycycline or Tetracycline
    • Atovaquone/proguanil (Malarone or non-branded)
    • Quinine

    Yes

    No

    3. Where are you travelling to?

      4. Date of travel?

        5. What is the duration of your travel in days?

          6. Will you be visiting the following areas?

            Jungle Areas
            Rural Areas
            High Risk Areas
            None Of The Above

            7. Are you pregnant or do you intend to become pregnant during your trip or within 3 months afterwards?

              We are unable to prescribe mefloquine (Lariam), doxycycline or atovaquone/proguanil (Malarone or non-branded). You will not be able to order these medications at the end of the consultation. Please continue.

              Yes

              No

              8. Are you breast-feeding or will you be during your trip?

                We are unable to prescribe mefloquine (Lariam), doxycycline or atovaquone/proguanil (Malarone or non-branded). You will not be able to order these medications at the end of the consultation. Please continue.

                Yes

                No

                9. Have you been diagnosed with liver disease?

                  We are unable to prescribe doxycycline, chloroquine, mefloquine (Lariam), chloroquine/proguanil. You will not be able to order these medications at the end of the consultation. Please continue.

                  Yes

                  No

                  10. Have you been diagnosed with kidney disease?

                  • Not including occasional urinary infection.
                  We are unable to prescribe chloroquine/proguanil, chloroquine, proguanil, mefloquine (Lariam) or atovaquone/proguanil (Malarone or non-branded). You will not be able to order thes medications at the end of the consultation. Please continue.

                  Yes

                  No

                  11. Do you have epilepsy or seizures?

                    We are unable to prescribe chloroquine/proguanil, chloroquine or mefloquine (Lariam). You will not be able to order these medications at the end of the consultation. Please continue.

                    Yes

                    No

                    12. Are you taking the anticoagulant warfarin (Used to thin the blood)?

                      We are unable to prescribe chloroquine/proguanil, doxycycline, proguanil or atovaquone/proguanil (Malarone). You will not be able to order those medications at the end of the consultation. Please continue.

                      Yes

                      No

                      13. Are you aware that no malaria tablet provides 100% protection?

                        No malaria tablet provides 100% protection. Please change your answer and continue.

                        Yes

                        No

                        14. Are you aware that if you get a fever between 1-week and 1-year after exposure you should seek medical attention and tell the doctor the background?

                          If you get a fever between 1 week and 1 year after exposure you should seek medical attention and tell the doctor the background. Please change your answer and continue.

                          Yes

                          No

                          15. Which travel vaccinations have you had in the last 10 years:

                            Hepatitis A
                            Hepatitis B
                            Typhoid
                            Yellow Fever
                            Rabies
                            Diptheria/ Tetanus/ IPV
                            Meningitis ACWY
                            Japanese Encephalitis
                            Cholera
                            Tickborne Encephalitis

                            16. Do all the following apply to you?

                            • I will read the patient information leaflet supplied with my tablets.
                            • The tablets are for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
                            • I am over 18.
                            The conditions must apply for you to be able to use this service.

                            Yes

                            No