Migraine Consultation

About your General Health

To help us provide the right treatment or advice for you, please answer the following questions about your overall health. If you get stuck or need any help, you can contact us.

Are you a female?

Yes

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

About your Condition

We need to understand more about your specific condition to help find the most suitable medication or advice to help you. Please can you answer the following questions. If you get stuck or need any help, you can contact us.

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

Yes

How often are you on average currently experiencing migraines?

Daily

A few times a week

Approximately once weekly

Fortnightly

Monthly

Every few months

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

Yes

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

Yes

Have you ever been diagnosed with any other medical conditions?

This can include:

-Immune system conditions such as HIV

-Liver or kidney issues

Yes

Do you suffer with any allergies?

Yes

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

Yes

Are you currently pregnant, planning a pregnancy or breastfeeding?

Yes

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

If so, please provide more information

Yes

The Agreement

This section is about making sure you agree to how any product should be used, understand our advice and the Terms and Conditions associated with the dispensing of medicines through WePrescribe.

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

Yes

I have read and understood the terms and conditions.

Please see our terms and conditions here

Yes

Migraine Consultation

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