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Do you believe you have the capacity to make decisions about your own healthcare?
YES
NO
Have you been diagnosed with any medical conditions?
YES
NO
Please provide more information, including diagnosis, symptoms and treatment.
Have you ever been diagnosed with a mental health condition?
YES
NO
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
YES
NO
Do you suffer from any allergies?
YES
NO
Do you suffer from any allergies?
YES
NO
Have you ever had any kind of cancer or kidney problems?
YES
NO
Have you ever had surgery to remove your spleen?
YES
NO
Please list all of the countries that you plan to visit on your upcoming trip (including how many days you are in each place)
Have you checked the NHS fit to travel website and confirmed that this treatment is recommended for the place you are visiting?
YES
NO
Please list all of the countries that you plan to visit on your upcoming trip (including how many days you are in each place)
When are you travelling (month and year)?
How many days long is your trip?
Can you confirm that you understand that you must follow extra precautions to avoid the risk of malaria, as well as taking this medication? These precautions include using a good quality insect repellent and using mosquito nets.
YES
Is your travel absolutely essential?
Yes my travel is essential
No my travel is not essential
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