Medical Assessment for Antiprotozoal

Patient Information  

Are you 18-65 years old?

For females, are you currently pregnant or breastfeeding?

Patient Symptoms  

Have you been told by your doctor that you have malaria, arthritis, amoebiasis, giardiasis, or lupus

OR are you experiencing any of the following symptoms?

• Fever and flu-like symptoms after traveling to a malaria-endemic region
• Yellowing of the skin and eyes after a history of travel
• Joint pain, swelling, or stiffness after a history of travel
• Foul-smelling, watery diarrhea
• Bloody diarrhea with stomach cramps

Medical History  

Do you have allergies to hydroxychloroquine, chloroquine, or nitazoxanide?

Do you have any of the following? 

• Epilepsy/seizure fits
• Depression, anxiety, or any psychiatric problem
• Vision problems
• Liver disease
• Kidney disease
• Irregular heart beat (heart arrhythmia)
• Skin condition psoriasis
• Blood condition porphyria
• G6PD deficiency
• HIV

Are you currently taking any of the following drugs? 

• Anti-arrhythmic drugs (amiodarone) for the heart
• Anti-psychotics (risperidone, olanzapine, clozapine)  
• Certain antibiotics (azithromycin, moxifloxacin)

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• You will regularly follow-up with your doctor if you are taking this medication for a long time
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber