Easonpharmacy.co.uk

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.

Source: http://easonpharmacy.co.uk/htdocs/Malaria_Prevention_Service_files/Malaria%20Assessment%20Form.pdf