Riley's Pharmacy Travel Health Questionnaire

Malaria is a risk in many tropical regions. If any of your destinations is a malaria risk area, these questions help us recommend the right prevention; if not, feel free to skip them. Malaria prevention is a prescription medication you take before, during, and after travel. We'll go over the options together at your appointment.
Important — you indicated you're currently pregnant. Three of the four standard malaria-prevention medications (doxycycline, Malarone, tafenoquine) are not options in pregnancy. We'll talk through chloroquine or mefloquine, and depending on your destination, may recommend deferring travel. Per WHO guidance, pregnant travelers are advised to avoid malaria areas where possible.
Have you ever taken malaria prevention medication before?
Which medications, and any side effects you experienced
Which medications, any side effects.
Any preference for malaria prevention on this trip?

Your privacy matters. The information on this form is Protected Health Information (PHI) under HIPAA. Riley's Pharmacy uses it only for your travel consultation, vaccine and medication recommendations, and follow-up care. We don't sell or share it with third parties for marketing. Ask us anytime for a full copy of our Privacy Notice.
Riley's Pharmacy Notice of Privacy Practices

PLACEHOLDER — Replace this content with Riley's actual NPP text via Form Builder, or add a downloadable PDF link. Required under 45 CFR § 164.520. The patient must see the NPP before they can acknowledge it.

Your Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.
AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION (Cal. Civ. Code § 56.11)

I authorize Riley's Pharmacy to use and disclose my medical information for the following purposes:
- Treatment communications with Riley's clinical team
- Notification of my primary care provider within 14 days of any vaccine or travel medication furnished (required under 16 CCR § 1746.5(e))
- Reporting administered vaccines to the California Immunization Registry (CAIR2), as required under H&S Code § 120440 / AB 1797 (mandatory, no opt-out for inclusion)
- Emergency contact disclosure — only that an emergency exists, not clinical details, unless I separately consent
This authorization remains in effect for the duration of my care at Riley's for travel-related services unless I revoke in writing. I have the right to revoke this authorization at any time by written notice to Riley's.
Privacy acknowledgment
Accuracy certification
Vaccine Information Statement (VIS) acknowledgment
Signature
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