• Antimalarial Medication Risk Assessment Form

  • Date of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Would you like your GP to be notified of this consultation*

  • Dates, itinerary and purpose of trip

  • Date of departure*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Return*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Personal Medical History

    tick which of the following applies to you
  • Are you feeling well today?*
  • Do you have any allergies to any medicines,?*
  • Do you have any recent or past medical history of note?
  • Are you taking any current or repeat medicines?*
  • Have you had a serious reaction to any antimalarial or doxycycline before?*
  • Do you known if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients?*
  • Do you suffer from epilepsy?*
  • Do you have a past history of black water fever?*
  • Do you have severe impairment of liver function?*
  • Do you suffer from any blood disorders such as thalassemia or sickle cell anaemia?*
  • Have you recently undergone radiotherapy, chemotherapy, steroids treatment?*
  • Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver, kidney, immunity, blood conditions, disorders, diabetes, immunosuppression, HIV-AIDs?*
  • Have you had any antimalarial medication or doxycycline before?

  • Women Only

  • Are you pregnant or planning a pregnancy?
  • Are you breastfeeding?
  • Should be Empty: