About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Do you have any allergies?
If yes, please provide details
What is your biological gender?
Please select your option
Are you the consumer of this medication?
If not, who is it for and how old are they? Please complete the consultation on the intended user's behalf.
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Do you have frequent or daily headaches despite the regular use of headache medication?
Do you have any heart or circulation problems?
If yes, please provide details
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
Do you consent to immediately stop taking the prescription medication we may supply for you and seek medical attention right away if any of the following symptoms occur:
Breathing that is slow or shallow.
Confusion.
Sleepiness.
Pupils that become small.
Being or feeling ill.
Constipation.
Appetite deficiency.
Do you suffer from any allergies?
If you do, kindly explain them below
Do you suffer from migraine attacks every day?
Have you been through menopause?
Do you have any neurological problems?
Do you experience visual disturbances or other neurological symptoms long after resolution of the headache?
Have you had a serious reaction or intolerable side effects to triptan products, antibiotics or any other medications before?
If yes, please describe the product and the reaction
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Women only: Are you breast feeding?
If male, select No.
Have you consulted a medical practitioner about your symptoms?
If you have, what was their recommendation?
Do you have any liver or kidney problems?
If yes, please provide details
How long have you had migraine symptoms?
Please select your option
Has your doctor told you that you suffer from migraines?
Please provide details in this box here...
Are you a heavy smoker, or do you use nicotine substitution therapies?
Do you have high blood pressure?
Have you had a stroke or a mini-stroke?
Do you have a seizure disorder (e.g. epilepsy) or a history of seizures?
If yes, please provide details
Please provide details of the migraine symptoms you experience
Please list all your current prescription medication including any medication you buy over the counter...
Please provide details of any recent or past medical history of note
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The Agreement
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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Women only: Are you pregnant or is there a possibility you may be pregnant?
Women only: are you currently breast-feeding?
How frequently do you get migraines?
Please select your option
Do any of the following symptoms accompany your headaches:
They only occur as a result of a brain damage.
Do you agree to the following?
You will read the patient information leaflet supplied with your medication.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
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.
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