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Malaria Prophylaxis
Patient name ______________________________________________ Name of GP (optional) _______________________________________ Address ___________________________________________________ Name & address of surgery (optional) ___________________________ ________________________________ Telephone _______________ __________________________________________________________ DOB ___________ Age _______ Weight (if under 40kg) ___________ __________________________________________________________ Name of parent/guardian, if patient under 16 years _________________ Would you like your GP to be sent a copy? Malarone or Doxycycline?
Please choose either Malarone or Doxycycline
Your Pharmacist wil advise which tablets are recommended.
Where are you travel ing (include al countries and districts) and how Malarone questions
__________________________________________________________ Do you have kidney disease (does not include __________________________________________________________ __________________________________________________________ Are you pregnant or breast-feeding or planning to __________________________________________________________ __________________________________________________________ OR
__________________________________________________________ Doxycycline questions
__________________________________________________________ Are you al ergic to Doxycycline or tetracycline? • Doxycycline & Malarone are equal y effective (neither is 100% effective) Have you been diagnosed with liver disease? • Both medications are taken daily.
Have you been diagnosed with the rare conditions of • Doxcycline is taken for 4 weeks after trip, Malarone for 1 week after.
• Doxcycline can cause sensitivity to sunlight. People taking it are advised to avoid strong sun, and to use high factor sun creams. Are you pregnant or breast-feeding or planning to become pregnant whilst taking Doxycycline? • Doxycycline usual y causes more side effects, the most common Do you suffer with acid indigestion or acid reflux? • Doxycycline is an antibiotic. It can cause tummy upset and reduce the effectiveness of the contraceptive pil . Important information
• Doxcycline is usual y lower cost than Malarone.
• No malaria prevention tablet is 100% effective.
• Doxycycline is not available to persons under 16 years.
Current Medications
• Read the Patient Information Leaflet supplied with your medication.
Please list your current medication. Include prescription medication and Confirm al questions are answered correctly __________________________________________________________________________________________________________________ _________________________________________________________ __________________________________________________________________________________________________________________ Patient’s Parent/Guardian’s Signature FOR PHARMACISTS USE ONLY
No ____________________________________
Doses of Malarone & Doxycycline & duration of treatment, including under 16 years and 11–40kg, see instructions for pharmacists (updated 24/2/12).
Medication supplied
Malarone Adult (Atovaquone/Proguanil 250mg/100mg) Malarone Paediatric (Atovaquone/Proguanil 62.5mg/25mg) Qty Name of Pharmacist Signature Date Cost copyright 2012 Pharmacy PGD - al rights reserved. Visit www.pharmacypgd.co.uk to download and print further forms.

Source: http://www.rosemountpharmacy.co.uk/resources/img/assessment-form-malaria.pdf


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