Are you currently taking any of the following medication (including over the counter, prescription or recreational drugs)?

medicines for blood clotting disorders or diabetes (e.g. warfarin) medicines for some mental problems (psychiatric disorders) medicines used to treat epilepsy (such as sodium valproate, carbamazepine, phenobarbital, phenytoin) medicines for any heart trouble, or high blood pressure (e.g. Quinapril) anti-biotics (e.g. tetracycline,rifampicin,rifabutin, penecillins, cephalosporins) antihistamines for allergies efavirenz or certain highly active protease-inhibitors (used to treat HIV) halofantrine tramadol (used to treat severe pain) ketoconazole (used to treat fungal infections) metoclopramide (used to treat nausea and vomiting) etoposide (used to treat cancer) medicines such as antacids containing aluminium, calcium or magnesium or other medicines containing iron, bismuth or zinc salts Ciclosporin (used to affect the body's immune response following organ transplants)

Have you confirmed the malaria tablets you have chosen are suitable for the countries you are visiting by checking the NHS fitfortravel website ?

Do you understand that if you experience any flu-like symptoms after returning from your trip for up to a year after you return, you should seek immediate medical attention and tell the doctor about your background and recent travel history?

Do you agree to the following?

You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. The treatment is solely for your own use You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Are you allergic to any of the following:

Atovaquone or proguanil chloride (Malarone) Doxycycline Mefloquine (Lariam) Quinine or Quinidine Chloroquine Any antibiotics

Have you ever been diagnosed with malaria?

Are you pregnant or breastfeeding or intending to become pregnant or start breast feeding?

Have you been diagnosed with any of the following?

kidney disesase liver disease mental health conditions (including depression or anxiety) epilepsy or convulsions myasthenia gravis, a condition characterised by muscle weakness, difficulty chewing and swallowing and slurred speech systemic lupus erythematosus (SLE) porphyria (a genetic disorder of the blood) Blackwater fever any serious medical condition which may require immediate hospitalisation