Migraine - WePrescribe

Migraine Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Have you ever previously been diagnosed with Migraines by your GP or another healthcare professional and if so have you experienced a benefit when taking any medication containing triptans?

Triptans are medications or brands such as; - Imigran - Sumatriptan - Maxalt melt - Zolmitriptan - Rizatriptan

Are you currently experiencing any of the following symptoms with your migraines?

- Double vision
- Seizures (fits)
- Ringing in the ears
- Numbness on one side of the face or body
- Any episode of a migrains lasting longer than 72 continuous hours
- Any recent rashes that accompany your migraines
- Loss of consciousness or reduced consciousness
- Loss of coordination

Have there been any significant changes in your migraines recently? Have they become worse or more frequent?

Have you ever been diagnosed with any other medical conditions?

This can include: -Immune system conditions such as HIV -Liver or kidney issues

Please provide more details

Do you suffer with any allergies?

If so, please provide more information

Please provide more details

Do you currently take any medication? This includes herbal remedies and over the counter medication.

If so, please provide more information

Please provide more details

Are you currently pregnant, planning a pregnancy or breastfeeding?

Is there any other information you would like to share with our prescribing team?

If so, please provide more information

Please provide more details

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

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