Consultation - Your Pharmacy Clinic

Malaria Prevention

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:Do you have any known allergies?

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Question 3:Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Question 4:Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Question 5:Do you smoke?

Question 6:Do you consume alcohol?

If yes, how much a day/weekly?

Question 7:How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Question 1:What is your destination country or region where malaria is prevalent?

Please provide more detail here

Question 2:What are the dates of your travel?

Question 3:Have you travelled to a malaria-endemic area before?

Question 4:Are you currently experiencing any symptoms that may suggest malaria? (e.g., fever, chills, headache, muscle aches)

Question 5:Have you been prescribed malaria prevention medication before?

Question 6:Are you currently taking any medication for malaria prevention?

Question 7:Have you experienced any side effects from your current or past malaria prevention medications?

Question 8:Have you tried any non-medication methods for malaria prevention? (e.g., insect repellent, bed nets, protective clothing)

Question 9:Have you used over-the-counter treatments for malaria prevention?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Question 1:Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for malaria.

Question 2:Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Question 3:Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Question 4:Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Travel Clinic

Assessment for Malaria Prevention

Malaria Prevention

1 About Your Health

Question 1:Do you have any known allergies?

Yes

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 3:Are you currently taking any medications?

Yes

Question 4:Have you had any surgeries in the past year?

Yes

Question 5:Do you smoke?

Yes

Question 6:Do you consume alcohol?

Yes

Question 7:How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Question 1:What is your destination country or region where malaria is prevalent?

Question 2:What are the dates of your travel?

Question 3:Have you travelled to a malaria-endemic area before?

Yes

Question 4:Are you currently experiencing any symptoms that may suggest malaria? (e.g., fever, chills, headache, muscle aches)

Yes

Question 5:Have you been prescribed malaria prevention medication before?

Yes

Question 6:Are you currently taking any medication for malaria prevention?

Yes

Question 7:Have you experienced any side effects from your current or past malaria prevention medications?

Yes

Question 8:Have you tried any non-medication methods for malaria prevention? (e.g., insect repellent, bed nets, protective clothing)

Yes

Question 9:Have you used over-the-counter treatments for malaria prevention?

Yes

3 The Agreement and Consent

Question 1:Understanding of Risks

Question 2:Medical Guidance

Question 3:Consent to Share Information

Question 4:Confirmation

Assessment Progress

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