Antimalarial Assessment | Pharma Aesthetics

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Antimalarial Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Antimalarial Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you recently experienced fever, chills, or severe sweats, which are common symptoms of malaria?*

Yes

No

Please provide more information below.*

Do you have a history of sudden, severe headaches and muscle pains that cannot be attributed to another medical condition?*

Yes

No

Please provide more information below.*

Have you been suffering from nausea or vomiting that appears unrelated to food intake or other known illnesses?*

Yes

No

Please provide more information below.*

Are you experiencing any unexplained fatigue or weakness that has persisted for several days?*

Yes

No

Please provide more information below.*

Have you noticed any dark urine or jaundice, a yellowing of the skin or eyes, which can sometimes occur in severe cases of malaria?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medication, including over-the-counter drugs or herbal supplements, that could interact with antimalarial medications?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you ever had an allergic reaction to antimalarial medication or do you have any known drug allergies?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any pre-existing medical conditions, such as G6PD deficiency, that could affect the choice of antimalarial treatment?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant, considering becoming pregnant, or breastfeeding, as this may influence the type of antimalarial that can be safely prescribed?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Will you be travelling to or residing in a region where malaria is endemic, necessitating prophylactic antimalarial treatment?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to ensure that any prescribed antimalarials are both effective and safe for the patient, considering their current health status and potential exposure to malaria.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Email

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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