Malaria medication questionnaire

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Please complete the anti-malaria questionnaire as accurately as possible to assist the surgery in knowing which is the most appropriate medication you require

Please visit: www.fitfortravel.nhs.uk to check which anti-malarial you need for your travel. Please leave sufficient time to request a private prescription before your journey to take the medication (some medication require several weeks to work)

www.fitfortravel.nhs.uk/destinations.aspx

FEE: Antimalaria prescriptions & medications are not available on the NHS and are private

The practice charge £15 per prescription for antimalarial medication. The pharmacist will charge separately for the actual medication

Please allow 3 working days after completing the form and contacting the surgery regarding collecting your prescription

Your Details

Please include your latest personal details so that we can contact you if necessary

The Patient's Full Name *

The Patient's Date of Birth *

Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980

The Patient's MOBILE number *

If the patient is a child please provide the parent's number. If we need to contact you to clarify your answers

The Patient's EMAIL address *

If the patient is a child please provide the parent's email address. If we need to contact you to clarify your answers

Travel questions

Date of DEPARTURE from the UK *

What date are you leaving the UK

YYYY

Date of RETURN back to the UK *

What date are you leaving the UK

YYYY

Which COUNTRY are you visiting? How LONG are you staying in each country (in DAYS)? Is the country being visits require antimalarias? *

i.e. KENYA - 5 days (YES requires antimalarials) and USA - 14 days (NO does not require antimalarials)

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