Are you registered with a GP practice in the UK?

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).

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

Are you aged between 18-65?

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

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

Do your migraines follow a broadly similar pattern each time?

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

• unilateral motor weakness
• double vision
• clumsiness or uncoordinated movements
• tinnitus (ringing in the ears)
• reduced level of consciousness
• seizure-like movements (fits)
• a recent rash with a headache
• headache confined to the back of the head
• recent marked deterioration in migraine (duration, severity or frequency of attacks)

Are you allergic to any medications or any other substances?

What is your blood pressure?

Do you drink alcohol?

Do you smoke?

Do you, or have you ever taken an MAOI antidepressant or any other form of antidepressant?

Do you experience pain or a feeling of pressure in the chest for more than a few minutes following taking migraine medication?

• Note: This is very rare but could be symptoms of a heart attack.

Have you previously been diagnosed with migraines by your GP and have you experienced relief when taking medication containing 'triptans' such as Imigran (Sumatriptan), Rizatriptan (Maxalt), Zomig (Zolmitriptan)?

When you have taken a ‘triptan’ medication in the past, within the first few hours of taking it have you experienced sensations such as heaviness, pressure or tightness in the body (especially chest or throat), or have you experienced palpitations, flushing, dizziness, rash, a feeling of weakness, worsening nausea and vomiting or a temporary rise in your blood pressure?

Are you breastfeeding or pregnant or possibly pregnant?

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

Have you been diagnosed with any of the following?

• Heart disease or heart problems such as narrowing of the arteries (ischaemic heart 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)
• High blood pressure
• Coronary Vasospasm (including Prinzmetal’s angina)
• Wolff-Parkinson-White Syndrome (a type of abnormal heartbeat)
• Peripheral Vascular Disease
• Previous Gastrointestinal or Splenic infarction
• Ischaemic Colitis
• Epilepsy or history of seizures
• Liver problems
• Kidney problems
• Allergy or sensitivity to antibiotics called sulphonamides (e.g. trimethoprim)
• Any serious medical condition which may require immediate hospitalisation

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

Do you agree to the following?

• 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 doctor or 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.