Assessment Progress

1Your travels
2Your health
3Consent

Assessment

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Patient Notice! This questionnaire forms the basis of your malaria consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medicinal information provided before selecting your treatment.

1Your travels

Which country or countries are you travelling to? *

Please select the medication recommended by www.fitfortravel.nhs.uk for your travel destination below: *

Have you ever suffered side effects from taking malaria tablets? *

NoYes

Please provide more information below. *

2Your health

Are you suffering or have you ever suffered from depression, anxiety or panic disorders? *

NoYes

Please provide more information below. *

Do you suffer from any problems with your kidneys, your urinary system, your digestive system or your liver? *

NoYes

Please provide more information below. *

Do you have any other health problems or conditions that you think we should know about? (e.g. mental illness, neurological conditions, Asplenia, recent or major operations, etc.) *

NoYes

Please provide more information below. *

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Do you have any known allergies to any medicine or other substances? *

NoYes

Please provide more information below. *

Are you pregnant or planning to become pregnant or breastfeeding? *

NoYes

Please provide more information below. *

Please confirm you aware that no malaria tablet will provide 100% protection. *

Confirm

Are you aware that if you get a fever between 1-week and 1-year after return, you should seek medical attention and tell the doctor you were in a malarial zone? Other possible symptoms are: feeling confused, muscle pains, loss of appetite, and yellow skin. *

Confirm

Please confirm you understand that if you are prescribed Malarone and vomit within 1 hour of taking your tablet, you should take another dose straight away. *

Confirm

Please confirm, if you are prescribed Malarone, that:

You have to start taking Malarone 1 to 2 days before travelling to an area which has malaria
You should continue taking it every day during your stay and you should continue to take it for another 7 days after your return to a malaria-free area

*

Confirm

3Consent

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Doctor terms and conditions. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

*

NoYes

Please enter the email address of your GP clinic *

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief video or phone call with one of our doctors. Do you have reliable access to the internet on a device which you can use to have a video conversation with our doctors? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

During your consultation, our doctor will assess whether you are suitable for treatment. If you are, a prescription will be provided to and filled by our pharmacy partner and delivered to your chosen address. Any and all resupplies will be stored on your account and will be available for request from our service when required. For resupplies you will only need to pay for the medication and shipping, you will not be charged a consultation fee. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request.

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation.

*

Confirm

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