Patient's personal details
Dates,itinerary and purpose of trip
Personal Medical History
Tick which of the following applies to you
Are you feeling well today?
Have you had any immunisations in the past 4 weeks?
Do you have any recent or past medical history of note?
Do you take any current or repeat medicines or are you talking halofantrine?
Do you have any allergies to any medicines, latex or eggs?
Have you had a serious reaction to a vaccine, antimalarial or doxycycline before?
Do you known if you are hypersensitive to mefloquine or related compounds (e.g. quinine, quinidine) or excipients?
Do you or any of your family suffer from epilepsy?
Do you have a past history of black water fever?
Do you have severe impairment of liver function?
Do you suffer from any blood disorders such as thalassemia or sickle cell anaemia?
Have you recently undergone radiotherapy, Chemotherapy, steroids treatments?
Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver, kidney, immunity, blood conditions, disorders, diabetes immunity, HIV AIDs?
Vaccination History
Have you had a vaccine, antimalarial or doxycycline before? (Please add dates)
Women Only
Tick which of the following applies to you
Please write below any further information which may be relevant e.g. Medicines, conditions..
