Migraine Assessment

20/11/2024 31/10/2025

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at enquiries@thefamilychemist.co.uk

Please urgently contact your GP or visit your nearest A&E if any of the following apply:

Your migraine is worse than usual
You have recently had a head injury
Your symptoms started suddenly or at the back of your head
You have a fever

About You

1. Hi. What is your name?

Do not order medication for another patient or order multiple medications for different patients on a SINGLE order. Please register separate accounts for each patient as each account is treated as a medical record.

2. Are you purchasing this medication for yourself?

STOP. Do not order medication for another patient or order multiple medications for different patients on a SINGLE order. Please use separate accounts for each patient.

Yes No

3. Are you aged between 18-65?

Yes No

4. Are you breast feeding, pregnant or planning to become pregnant?

Yes No

4b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are

Medical History

5. What symptoms do you usually experience? (select all that apply)

Pain in the head face or neck that's on one side

Pain in the head face or neck that's on both sides

Throbbing or banging headache

Mild to moderate pain

Moderate to severe pain

Sensitivity to light, sound or nausea and vomiting

None of the above

6. Do you experience a migraine for 4-72 hours or migraines for less than 10 days a month?

Yes No

7. Have you previously been diagnosed with migraines by your GP?

Yes No

8. What is your blood pressure?

Low - Below 90/60

Normal - Between 90/60 - 140/90

High - Above 140/90

9. Are you experiencing any of the following along with your migraine?

Weakness of one side of the body
Double vision or loss of vision
Clumsiness, uncoordinated movements or reduced level of consciousness
Ringing in the ears (tinnitus) or hearing loss
Physically unable to speak
Sudden-onset severe headache
A recent rash and/or fever with a headache
Headache triggered by coughing, sneezing, bending or exertion
Headache worsened on lying down or standing
Recent marked deterioration in migraine (duration, severity or frequency of attacks)

Yes No

10. Do any of the following apply to you?

Migraine headaches started after the age of 40 and you have not seen your GP about them
New headaches and other signs of being unwell (e.g. unintentional weight loss, neurological symptoms, eye symptoms) and you have not seen your GP about them

Yes No

10b. Please provide more details:

11. What other treatments have you used before for your migraines? (select all that apply)

Painkillers such as paracetamol, ibuprofen or co-codamol

Triptans such as Sumatriptan, Imigran or Maxalt Melt

Antisickness medications such as Buccastem

Preventative medications such as propranolol, amitriptyline

Other medications

None of the above

12. Have you had a recent (usually with the past 3 months) head injury?

Yes No

13. Have you been diagnosed with any of the following?

Heart disease or heart problems such as narrowing of the arteries (ischaemic heart disease), peripheral vascular disease or chest pains (angina), or have already had a heart attack
Stroke or a mini-stroke (also called a transient ischaemic attack or TIA)
History of seizures

Yes No

13b. Please provide more details:

Past Medical History

14. Do you have any kidney or liver impairment?

Yes No

14b. Please provide more details:

15. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

15b. Please provide more details:

16. Are you currently taking or recently stopped taking any of the following medicines, other prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Itraconazole, fluconazole
Clarithromycin, erythromycin
Diltiazem, quinidine, verapamil
Ritonavir and efavirenz
Bosentan
St. John’s Wort
Phenobarbital
Rifampicin
Modafinil
Cyclosporin
Medicines such as Fremanezumab (Ajovy), Galcanezumab (Emgality) or Erenumab (Aimovig)

Yes No

16b. Please provide more details:

17. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

17b. Please provide more details:

18. Would you like us to contact your GP?

Yes No

18b. Please search for your GP.

Please Provide GP Email (preferred):

Unable to find your surgery? Click Here

19. Do you give consent for our clinical team to check your NHS Summary Care Records if required?

Yes

20. Do you agree with all of the the following?

I am aware that different triptan medications should not be used within 24hours of each other or for the same migraine attack.
I understand that Vydura (rimegepant) can only be used as a preventative medication if I experience 4 or more migraine attacks per month and will not use it for prevention if this does not apply to me.
I have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
I have answered the questions honestly and accurately and the treatment is solely for my personal use.
I will read and understand the patient information leaflet supplied with my medication.
I understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
I understand prescribing decisions will be based on the answers from my consultation and incorrect information can cause harm to my health. Orders may be rejected if not clinically suitable.
I am aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
I have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes

21. I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet

Yes

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Migraine Assessment

About You

Medical History

Past Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

13 Poplars Court,
Nottingham,
NG7 2RR

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Today’s Responsible Pharmacist

About You

Medical History

Past Medical History

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