Sumatran Relief Pharmacist Consultation

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In order for our pharmacists to asses whether you can safely take Sumatran Relief, please complete the following seven questions. All answers are strictly confidential.
The person intending to take this medication must be the person to complete this form.

Email *

Your Name *

1) Have you previously been diagnosed by a doctor with migraine? *

Yes

2) What is your age? (Years) *

3) Which of the following symptoms do you have with your migraine? *

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? *

Less Than 24hrs

More Than 24hrs

5) Do you regularly take headache medications for more than 10 days per month? *

Yes

6) Are you pregnant? *

Yes

7) Do you have or previously had any of the following conditions? *

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

Send me a copy of my responses.

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