Migraine Treatment Consultation

STEP 1 OF 2

Personal Information

Please provide your details and migraine information

Name *

First

Last

Date of birth? *

YYYY

Phone Number? *

Address? *

Email *

What is your gender? *

MALE FEMALE

Please specify which treatment you are looking for? Please select don't know if you are not sure. *

If Others, Please Specify:

Did your migraine started after the age of 50? *

YES NO

Did you experienced your first migraine attack last year? *

YES NO

Which healthcare professional diagnosed you with Migraine? *

Your doctor or specialist Self diagnosis If other, please specify:

Please specify the symptoms of your migraine? *

Weakness on one side of your body Vision loss or double vision Uncoordinated or clumsy feeling Ringing in the ears or trouble hearing Unable to control parts of your body or speech None of the above

If other, please specify:

Important: If you have severe headache which is worse than previous migraine or you had recent head injury, sudden occipital headache or having fever and rashes on your body you should attend Accident and emergency.

I Understand

STEP 2 OF 2

Medical History

Please provide details about your medical history and current medications

Do you have any past medical history of heart attack, angina, heart failure, stroke, TIA, Leg claudication ( circulation problems in your leg) that cause pain in your leg when you are walking? *

NO If YES, please specify:

Do you have any past medical history of high blood pressure, epilepsy, liver or kidney disease or any other medical or surgical condition that you want to inform to our doctor? *

NO If YES, please specify:

Please answer the following question if they apply to you. *

You have high cholesterol A parent, brother or sister developed heart disease before they were 60 You smoke more than 10 cigarettes a day or use nicotine replacement therapies You are diabetic None of the above

If other, please specify:

Are you currently taking any prescription, non prescription or illegal drug or herbal medication? And have you recently taken any medication in the last two weeks? Please specify. *

NO If YES, please specify:

Please specify if you have allergy to any medication or any other substance? *

NO If YES, please specify:

Do you have any past medical or surgical history? If yes please specify below.

Understanding and Honesty * I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge.

Treatment Consent * I understand the side-effects and effectiveness of the above mentioned treatment and I am giving consent to continue with my request.

Please specify the name of preferred pharmacy where you want to collect your prescription/medications? *

Personal Use Confirmation * I am confirming that the treatment prescribed above will be for my personal use.

CHECKOUT

Checkout

Complete your consultation payment

Consultation Summary

Migraine Treatment Consultation €25.00

Total €25.00

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