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Sumatran Relief Pharmacist Consultation
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Name
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Your answer
Email
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Your answer
Address
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Your answer
1) Have you previously been diagnosed by a doctor with migraine?
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Yes
No
2) What is your age? (Years)
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Your answer
3) Which of the following symptoms do you have with your migraine?
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Intense throbbing/pulsating headache
Usually on one side of the head
Worsened by routine physical activity
Nausea (sometimes with vomiting)
Sensitivity to light, noise or smells
Required
4) How long do your migraine headaches usually last?
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Less Than 24hrs
More Than 24hrs
5) Do you regularly take headache medications for more than 10 days per month?
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Yes
No
6) Are you pregnant?
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Yes
No
7) Do you have or previously had any of the following conditions?
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Myocardial infarction (heart attack), ischaemic heart disease or coronary vasospasm
Hypertension (high blood pressure)
Stroke or cardiac arrhythmia
Kidney or liver disease
History of seizures or other risk factors which lower the threshold
Management of basilar, hemiplegic or ophthalmoplegic migraine
None of the above
Required
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