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Migraine Consultation Form

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

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Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?
What is your Date of Birth?
Day
Month
Year
Have you been diagnosed with any medical conditions?
Have you ever been diagnosed with a mental health illness?

If Yes Give Details

Have you had any Migraine treatment before?
Are you pregnant, breastfeeding, possibly pregnant or intending to become pregnant?
Have you been diagnosed with migraines by your doctor?
How many migraines do you experience on average per month?
Do your migraines last longer than 24 hours, or last less than 4 hours without treatment?
Do your migraines follow a similar pattern every time you have one?
Do you experience any symptoms with your migraine?
What symptoms do you experience any with your migraine?
Have you experienced relief when taking medication containing 'triptans' such as Imigran (Sumatriptan), Rizatriptan (Maxalt), Zomig (Zolmitriptan)?
Have you previously experienced feelings listed below when previosuly taking 'triptans' or migraine medication? heaviness, pressure or tightness in the body (especially chest or throat) palpitations, flushing or dizziness, rash feeling of weakness, wors
Are you allergic to Imigran/Sumatriptan, Maxalt/rizatriptan, Zomig/zolmitriptan?
Do you suffer from any of the following? Heart disease or heart problems or chest pains (angina), or have had a heart attack Stroke or a mini-stroke (also called a transient ischaemic attack or TIA) High blood pressure Coronary Vasospasm (including Pri
Are you currently taking any prescription medication, over the counter, medication, recreational drugs or herbal medication?
Are you taking any of the following medications? Migraine medications Ergotamine or Methysergide Any other ‘triptan’ migraine medication (e.g. naratriptan, rizatriptan, zolmitriptan, almotriptan or eletriptan (NOTE: we advise different types of ‘triptans
Please confirm the below; I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform
Would you like us to inform your GP of the treatment you chose to order with us today?
Product
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