1. Have you read the ‘Malaria’ section on the NHS ‘Fit for travel’ site?

2. Can you confirm that you have selected the correct medication based on the advice provided by the NHS Fit for Travel website?

3. Please confirm you have read the ‘Mosquito Bite Avoidance’ section of the Fit for travel site.

4. Are you aware that no malaria tablet provides 100% protection?

5. Are you pregnant, breast feeding or intending to become pregnant (within 3 months afterwards)?

6. Are you aware that if you get a fever between one week after first potential exposure and up to one year after your return from a country with malaria you should seek medical attention urgently and tell the doctor that you have been in a malaria risk area?

7. Mefloquine can induce psychiatric symptoms such as anxiety disorders, paranoia, depression, hallucinations, psychosis, nightmares, restlessness and confusion. The medication can remain in your body for months after stopping the course. Should you experience any change in your state of mind you should stop taking this medication immediately and consult a doctor as soon as possible. Please confirm you have understood this advice.

10. Have you been diagnosed with any of the following? • Mental health problems including but not limited to depression, generalized anxiety disorder, psychosis, suicide attempts, suicidal ideations and self-endangering behaviour, schizophrenia. • Epilepsy or other seizure disorder • Traumatic brain injury • Cardiac conduction disorders ie problem with electrical activity of the heart. E.g Atrial fibrillation, long QT syndrome. • Blackwater Fever • Kidney problems • Liver problems

11. Are you taking any of the following medications? • Heart/Circulation medications such as  Anti-arrhythmic medication e.g Amiodarone, Disopyramide, Dronedarone, Verapamil  Beta-blockers eg Atenolol, Betaxolol eye drops, Bisoprolol, Carvedilol, Propranolol, Sotalol, Timolol  Calcium channel antagonist blood pressure medications eg Amlodipine, Diltiazem, Felodipine, Nifedipine  Digoxin  Ranolazine  • Anagrelide • Anti-depressants • Anti fungals eg Fluconazole, Itraconazole, Ketoconazole, • Anti-psychotics • Antibiotics from the macrolide class eg Clarithromycin, Erythromycin • Amifampridine • Apomorphine • Artemether • Artenimol • Bedaquiline • Betaxolol • Chemotherapy or related cancer drugs • Erectile dysfunction medication eg Sildenafil (Viagra), Vardenafil • Halofantrine • HIV medications eg Efavirenz • Hydroxyzine • Lithium • Methadone • Moxifloxacin • Ondansetron • Quinine • Rifampicin • Tolterodine

Standard T&C • I will read the patient information leaflet supplied with my medication • I will contact my GP or MyMedsUK if I experience any side effects • The treatment is for my use only • I have answered the assessment questions truthfully and accurately • I agree to the Terms and Conditions and I confirm that I am over 18 years old • I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription.