PATIENT ASSESSMENT FORM Malaria Prophylaxis
Patient name ______________________________________________
Name of GP (optional) _______________________________________
Address ___________________________________________________
Name & address of surgery (optional) ___________________________
__________________________________________________________
__________________________________________________________
Contact telephone __________________________________________
__________________________________________________________
DOB _______________________________________ Age __________
Would you like your GP to be sent a copy?
Malarone or Doxycycline?
Please choose either Malrone or Doxycycline Malarone 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
__________________________________________________________
__________________________________________________________
Do you weigh less than 40kg (6 Stone 4lb)?
__________________________________________________________
Are you pregnant or breast-feeding or planning to
____________________________________________________________________________________________________________________
OR
__________________________________________________________
Doxycycline questions
__________________________________________________________
Are you al ergic to Doxycycline or tetracycline?
• Doxycycline and Malarone are equal y effective (neither is 100%
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 a trip, Malarone for 1 week
Are you pregnant or breast-feeding or planning to
• Doxcycline can cause sensitivity to sunlight. People taking it are
become pregnant whilst taking Doxycycline?
advised to avoid strong sun, and to use high factor sun creams.
Do you suffer with acid indigestion or acid reflux?
• Doxycycline usual y causes more side effects, the most common
• Doxycycline is an antibiotic. It can cause tummy upset and reduce
Important information
the effectiveness of the contraceptive pil .
• Doxcycline is usual y lower cost than Malarone.
• No malaria prevention tablet is 100% effective.
• Malarone supplied only for 28 days (37 tablets), Doxycycline for 3
• Read the Patient Information Leaflet supplied with your medication. Current Medications
Confirm al questions are answered correctly
Please list your current medication. Include prescription medication and over the counter medications/drugs:
__________________________________________________________
__________________________________________________________
__________________________________________________________
FOR PHARMACISTS USE ONLY
________________________________________________________________________
________________________________________________________________________
Medication supplied Medication Qty Name of Pharmacist Signature Date Cost
copyright 2011 Pharmacy PGD - al rights reserved. Visit www.pharmacypgd.co.uk to download and print further forms.
See also Chapter 7, LIA technique for TKA • Bupivacaine 0.25% or ropivacaine 0.25% delivered Review of evidence intra-articularly as wel as subcutaneously at the• Four clinical trials have shown a beneficial effect ofdonor site, via indwel ing catheter, at at least 4 mL/hcontinuous delivery of ropivacaine (Andersen KV et al. for 48 h, improves pain relief and reduces opioid2010; Bia
Research at the primate center spans a broad spectrum of human health issues, ranging from asthma to Alzheimer’s, and HIV to stem cell therapies. Because of the close similarities to humans in both their physiology and behavior, nonhuman primates are critical models in the development of advancements in human medicine. CNPRC researchers are engaged in research projects that are making valuabl