Raf

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symtoms

Do you experience migraines for more than 10 days a month?

Yes No

Do your migraines last less than 4 hours without treatment or last longer than 24 hours?

Yes No

How often do you suffer from migraines?

Select the most appropriate answer:
Daily
Every few days
Weekly
Fortnightly
Monthly
Every few months

Have you had your migraines diagnosed by a doctor?

Yes No

Please select the symptoms that you experience:

Select one or more answers:
Headache
Nausea
Vomiting
Sensitivity to light
Sensitivity to sound
Visual disturbance

Health

Do you suffer from any of the following:

Headaches that last more than three days consecutively.
Migraine associated with temporary weakness or numbness of one side of the body.
A constant headache which is made worse by bending over or coughing or sneezing.
A headache which wakes you from sleep.
Double vision.
Muscle weakness.
Ringing in your ears (tinnitus) that pulses with your heart beat or recent onset hearing loss.
A loss of balance.
Dizziness that gets better if you lie down.

Yes No

Are your headaches associated with any of the following symptoms:

They occur only after an injury to the head.
They reach their peak intensity in 5 minutes or less.
They occur alongside a loss of speech, sensation, power, or consciousness.
They occur alongside fever or neck stiffness.
They occur alongside tenderness around your temples.

Yes No

Are you currently taking, or have you previously tried, any treatments for migraine? medication containing 'triptans' such as Imigran (Sumatriptan), Rizatriptan (Maxalt), Zomig (Zolmitriptan)

Yes No

Are you pregnant or breastfeeding?

Yes No

Do you have an allergy (hypersensitivity) to Imigran/Sumatriptan, Maxalt/rizatriptan, Zomig/zolmitriptan?

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Do you take any of the following medicines:

Ergotamine or methylsergide.
MAOIs (e.g. moclobemide or selegiline).
SSRIs (e.g. citalopram, fluoxetine or sertraline) or other medicines for depression.
Lithium.
St. John's Wort (a herbal remedy).
Cimetidine (for indigestion or stomach ulcers).
A quinolone antibiotic (e.g. ciprofloxacin).

Yes No

Agreement

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
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.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Medical Assesment Migraine