Malaria Prevention - WePrescribe

Malaria Prevention Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

What is your weight?

Have you ever previously been diagnosed with a kidney condition?

Have you ever suffered with any allergic reactions to any antimalarial medication previously?

Have you ever previously been diagnosed with any other medical conditions?

This includes conditions such as - Asthma - Kidney disease - Liver disease - Eczema

Please provide more details

Please indicate where you will be travelling too and how many days you will be at your destination (this includes the day of arrival and day of leaving even if these are only for a short period of time)

Do you suffer with any allergies?

If so, please provide more information

Please provide more details

Do you currently take any medication? This includes herbal remedies and over the counter medication.

If so, please provide more information

Please provide more details

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Is there any other information you would like to share with our prescribing team?

If so, please provide more information

Please provide more details

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

Malaria Prevention Consultation

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