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Migraine

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 [email protected]

About You

1. Are you purchasing this medication for yourself?
2. Are you aged between 18-65?
3. Are you breast feeding, pregnant or planning to become pregnant?

Medical History

4. Do you experience a migraine for 4-72 hours or migraines for less than 10 days a month?
5. Have you previously been diagnosed with migraines by your GP?
6. What is your blood pressure?

7. 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
  • 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)

Please provide more details:

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

9. 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

Please provide more details:

Past Medical History

10. Do you have any kidney or liver impairment?

Please provide more details:

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

Please provide more details:

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

Please provide more details:

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

Please provide more details:

14. Would you like us to contact your GP?

15. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

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

Please click "Yes".