Have you previously been diagnosed with migraine by a GP or specialist?

How long have you been experiencing migraine symptoms?

How often do you experience migraine attacks?

How long do your migraine attacks typically last if untreated?

Do your headaches usually affect one side of the head?

Do you experience any of the following symptoms with your migraines?

Do you experience aura symptoms before your migraine begins?

Aura symptoms are temporary neurological disturbances like visual changes, tingling, or speech difficulty that occur before a migraine.

Have your headaches recently changed in severity, frequency, or pattern?

Have you ever experienced weakness, difficulty speaking, confusion, or loss of consciousness during a headache?

Do your headaches ever wake you from sleep or occur first thing in the morning?

Do you have any of the following medical conditions?

Are you currently taking any regular medication or treatments for migraine?

Have you been prescribed treatment from a GP for this before?

The Agreement & Consent

Do you agree to and understand the following?

• I have been informed about the potential side effects and interactions of the prescribed medication for Migraine.

• I agree to consult with my healthcare provider before starting any new medication.

• I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

• I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

• I understand that my information will be kept confidential and used solely for the purpose of this assessment.

• I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

• I understand that providing false information may result in my order being cancelled and may have health implications.