Treatment Questions – Youth And Earth Labs

How did you hear about us?

I confirm the above statements are true This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers, please verify the information with your GP before using the service:

--I am 18 years old or above.
--I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.

I confirm the above statements are true

Please confirm that you understand this Please note the following important points:

--Before completing this questionnarie, it is essential that you have looked at the TravelHealthPro website to see which malaria pills are recommended for where you are going.
--Do not use this service if you have a condition that suppresses your immune system- you should see your GP.
--Avoid insect bites as well as taking anti-malarial tablets while abroad. No tablet is 100% effective.
--See a doctor if you get a high fever within one year of being in a malarial area, as you will need testing for malaria.

Please confirm that you understand this

We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Countries to be visited

What is your sex?

Male Female

What is your date of birth?

Date

Month

Year

First country you are visiting

Please tell us which area(s) of this country you will be travelling to

Are you visiting any other countries?

Yes No

When are you first arriving in a malaria area?

Malaria pills

Have you looked on the TravelHealthPro website to ensure malaria pills are recommend in the countries you have listed above?

Yes No

Does the TravelHealthPro website recommend the specific malaria pills you are requesting for all the countries you have named above?

Yes No

If you have previously taken the specific malaria pill you are requesting, did you experience any side-effects?

Yes No

Current and recent use of medicines

Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?

Yes No

Allergies

Are you allergic to any of the following? Please select all that apply.

Penicillin Grass,pollen,trees,plants (Hay fever) House dust Animals (Dogs,cats,horses etc) Nuts

Do you have any other known allergies?

Yes No

Your general health

Do you weigh less than 40kg (6 stone 3lbs)?

Yes No

Have you ever been diagnosed with a liver condition?

Yes No

Have you ever been diagnosed with a kidney condition?

Yes No

Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?

Yes No

Pregnancy and breastfeeding

How do I know if I\'m pregnant?

Yes No

Are you breastfeeding?

Yes No

I confirm the above statements are true --I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.
--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Youth and Earth Labs Online Doctor before proceeding.
--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
--I have read, understand and agree to the latest terms and conditions and privacy policy.

I confirm the above statements are true

Malaria

Malaria is a serious disease, spread by mosquitoes, and is widespread in many tropical and subtropical countries. There is no vaccination, so it is highly recommended that you take malaria tablets if you are visiting an area at risk.

Countries to be visited

Malaria pills

Current and recent use of medicines

Allergies

Your general health

Pregnancy and breastfeeding

0% of questionnaire complete