Consultation

Q No.	Question	Answer
1	Have you ever had an allergy (hypersensitivity) to anti-malarials? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
2	Have you ever been diagnosed with malaria? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
3	Are you pregnant or breast feeding or intending to become pregnant or start breast feeding within the next 6 months? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
4	Have you been diagnosed with any of the following? • Depression or psychiatric disorders • Epilepsy or Convulsions • Liver disease • Kidney disesase • SLE, Myasthenia Gravis or galactose intolerance You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
5	Are you taking any of the following medication? • Anti-coagulant medications (e.g. warfarin) • Metoclopramide • Etoposide (a cancer drug) • Rifampicin • Rifabutin • Tetracyclines • Valproate • Barbiturates • Carbamazapine • Phenytoin • Ciclosporin • Ketoconazole You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
6	Are you aware that if you experience any flu-like symptoms after returning you should seek immediate medical attention and tell the doctor about your background and recent travel history? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
7	Do you agree to the following? • You will seek medical attention if you experience any unusual side effects • The treatment is solely for your own use • You will read the patient information leaflet supplied with your medication You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
8	Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability. You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo