PATIENT ASSESSMENT FORM Malaria Prophylaxis UPDATED TO INCLUDE MALARONE PAEDIATRIC AND OTHER UPDATES, USE wITH UPDATED INSTRUCTIONS SHEET (24/2/12)
Patient name ______________________________________________
Name of GP (optional) _______________________________________
Address ___________________________________________________
Name & address of surgery (optional) ___________________________
________________________________ Telephone _______________
__________________________________________________________
DOB ___________ Age _______ Weight (if under 40kg) ___________
__________________________________________________________
Name of parent/guardian, if patient under 16 years _________________
Would you like your GP to be sent a copy?
Malarone or Doxycycline?
Please choose either Malarone 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
__________________________________________________________
__________________________________________________________
Are you pregnant or breast-feeding or planning to
__________________________________________________________ __________________________________________________________
OR
__________________________________________________________
Doxycycline questions
__________________________________________________________
Are you al ergic to Doxycycline or tetracycline?
• Doxycycline & Malarone are equal y effective (neither is 100% effective)
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 trip, Malarone for 1 week after.
• Doxcycline can cause sensitivity to sunlight. People taking it are
advised to avoid strong sun, and to use high factor sun creams.
Are you pregnant or breast-feeding or planning to
become pregnant whilst taking Doxycycline?
• Doxycycline usual y causes more side effects, the most common
Do you suffer with acid indigestion or acid reflux?
• Doxycycline is an antibiotic. It can cause tummy upset and reduce the
effectiveness of the contraceptive pil .
Important information
• Doxcycline is usual y lower cost than Malarone.
• No malaria prevention tablet is 100% effective.
• Doxycycline is not available to persons under 16 years. Current Medications
• Read the Patient Information Leaflet supplied with your medication.
Please list your current medication. Include prescription medication and
Confirm al questions are answered correctly
__________________________________________________________________________________________________________________
_________________________________________________________
__________________________________________________________________________________________________________________
Patient’s Parent/Guardian’s Signature
FOR PHARMACISTS USE ONLY No ____________________________________
Doses of Malarone & Doxycycline & duration of treatment, including under 16 years and 11–40kg, see instructions for pharmacists (updated 24/2/12). Medication supplied Medication
Malarone Adult (Atovaquone/Proguanil 250mg/100mg)
Malarone Paediatric (Atovaquone/Proguanil 62.5mg/25mg)
Qty Name of Pharmacist Signature Date Cost
copyright 2012 Pharmacy PGD - al rights reserved. Visit www.pharmacypgd.co.uk to download and print further forms.
Psychiatric Medication for Children and Adolescent Part II – Types of Medications Psychiatric medications can be an effective part of the treatment for psychiatric disorders of childhood and adolescence. In recent years there have been an increasing number of new and different psychiatric medications used with children and adolescents. Research studies are underway to establish more clear
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