PATIENT PERSONAL DETAILS

Personal medical history

Tick which of the following applies to you

Are you feeling well today?
Have you had any immunisations in the past 4 weeks?
Do you have any recent or past medical history of note?
Do you take any current or repeat medicines or are you taking halofantrine?
Do you have any allergies to any medicines, latex or eggs?
Have you had a serious reaction to a vaccine, antimalarial or doxycycline before?
Do you know if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients?
Do you or any of your family 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 thalassaemia 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, immunity, HIV-AIDs?

Vaccination history

Have you had a vaccine, antimalarial or doxycycline before? (PLEASE ADD DATES NEXT TO VACCINE TYPE)

PATIENT CONSENT

I have received information on the risks and benefits of the medicines recommended and fully understand them. I have also had the opportunity to ask questions. I consent to the recommended medicines being given at each appointment.

OUR SERVICE IS A PRIVATE SERVICE AND NOT COVERED BY THE NHS