Rxpress

Are you currently taking any medications (prescription or non-prescription)?
YesNo

If yes, please specify:

Have you received oral or parenteral antibiotics within the last 14 days?
YesNo

If yes, please specify:

Have you had a high fever or temperature in the last 24 hours?
YesNo

If yes, please specify:

Are you taking regular medication that thins your blood (excluding aspirin 75mg)?
YesNo

If yes, please specify:

Have you had past or recent surgery?
YesNo

If yes, please specify:

Are you pregnant, planning pregnancy or possibly pregnant?
YesNo

If yes, please specify:

Are you breast-feeding?
YesNo

Do you have ongoing medical problems?
YesNo

If yes, please specify:

Do you have any bleeding disorders?
YesNo

If yes, please specify:

Are you receiving dialysis?
YesNo

Have you been told you may have low immunity?
YesNo

If yes, please specify:

Family history of congenital/hereditary immune disorders?
YesNo

Do you feel faint or stress reactions when vaccinated?
YesNo

Any severe reactions to previous vaccines?
YesNo

If yes, please specify:

Do you have any allergies (e.g., eggs, antibiotics, nuts)?
YesNo

If yes, please specify:

Sugar intolerance (e.g., galactose intolerance, Lapp lactase deficiency)?
YesNo

Do you suffer from thymus dysfunction?
YesNo

If yes, please specify:

Have you had your school leavers DTP vaccine?
YesNoUnsure

If yes, please specify:

Do you have any cerebral disorders (e.g., epilepsy or stroke)?
YesNo

If yes, please specify:

Have you taken antimalarials before?
MefloquineDoxycyclineAtovaquone/ProguanilChloroquineProguanilUnsure

Any problems taking malaria medication before?
YesNo

If yes, please specify:

Serious liver problems requiring specialist review?
YesNo

If yes, please specify:

Serious kidney problems requiring specialist review?
YesNo

If yes, please specify:

Kidney failure due to malaria or Blackwater fever?
YesNo

If yes, please specify:

Do you or close family have epilepsy?
YesNo

Any psychiatric history (even mild or isolated)?
YesNo
AnxietyPanic attacksDepressionAny other psychiatric problems

If yes, please specify:

Received any blood products (immunoglobulins) in last 3 months?
YesNo

Any other health or medical information we should know?
YesNo

If yes, please specify: