____Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. *You should contact your GP urgently or go to your local A+E if any of the following situations apply, as these can be a sign of a more severe headache: your migraine is worse than normal you have recently had a head injury your headache started suddenly or at the back of your head you have a fever Please tick to confirm that you understandHave you ever been told by a doctor that you have migraines? *YesNoThis could be your GP or a neurologist or headache specialist. take it? to Have your migraines changed since you last saw your doctor? *YesNoFor example have you noticed any new symptoms or have they become more severe.How have these changed? *Why do you think you have migraines?What treatments have you used for your migraines in the past? *Painkillers, for example paracetamol or ibuprofenTriptan medications, for example sumatriptan, Imigran or Maxalt MeltAntisickness medications, for example Buccastem MOther medicationsI haven't used any treatments beforeHave you spoken to your doctor about your triptan treatment since first using it? *YesNoDid the triptan treatment help with your migraine symptoms? *YesNoPlease give more details:Do your migraines ever: Please select any symptoms that happen during your migraine attacks. *cause weakness down one side of your body (hemiplegic migraines)?cause partial or total loss of vision in one eye (ophthalmic or ocular migraines)?make you more uncoordinated or clumsy than normal (basilar migraines)?give you ringing in the ears or trouble hearing (basilar migraines)?make you physically unable to speak?none of the aboveUnlike an aura, these symptoms might persist alongside your headache or recur with your headache.Do you have, or have you ever had, any of the following conditions: *a heart attack or anginaan irregular heart beatother heart or circulation conditionshigh blood pressurehigh cholesteroldiabetesepilepsy or seizuresa stroke or mini-strokea neurological condition - such as Parkinson's diseaseliver problemskidney problemsphaeochromocytomarheumatoid arthritis or systemic lupus erythematosus (SLE)none of these conditionsPlease provide more details.Do you have any other medical conditions? *YesNoAny medical conditions that are not mentioned above.Please provide more details. (copy)Has someone in your immediate family (mother, father, brother, sister) been told they have cardiovascular disease when they were under 60 years old? *YesNoCardiovascular disease includes: a heart attack, a stroke, angina, conditions affecting the blood vessels.Do you smoke? *YesNoI am using nicotine replacement therapy to help to stop smokingHow many cigarettes do you smoke a day?less than 1010 or more What is your height?Enter in ft and in or cm | We use this information to calculate your BMI (body mass index).Feets *Inches *or CMs * What is your weight?Enter in pounds/lbs or kg | We use this information to calculate your BMI (body mass index).KGs *LBs *Are you pregnant or breastfeeding? *NoI'm pregnantI might be pregnant, I’m not sureI'm breastfeedingOtherPlease provide more details.If you are breastfeeding it is possible to use triptan medications. The amount of the medication that is found in breastmilk is probably too small to be harmful, however the manufacturer recommends avoiding breast feeding for 12 hours after treatment and to express and discard breastmilk during this time.Are you happy to stop breastfeeding for 12 hours after using any triptan medications? *YesNoAre you taking any of the following medication? *BosentanClarithromycinEfavirenzItraconazoleModafinilPhenobarbitalRifampicinRitonavirNone of the aboveIt's very important for us to know about anything else you're taking, since some medication or over the counter supplements may interact with treatments we provide.Are you currently using any other medication, even if you’re not taking it regularly? Or have you finished a course of medication in the last month? *YesNoIncluding over-the-counter medications and herbal treatmentsPlease select all of the relevant medications: *Medications for mental health conditions - including antidepressants, sedatives, anti-anxiety treatments and mood stabilisersAntisickness medicationsSt Johns WortPropranololMedications for high blood pressureCabergoline, Levo-dopa or RopineroleOther medicationsPlease tell us the name of the medication and what you use it for.Are you allergic to any medicines or other substances? For example lactose. *YesNoAre you allergic to: *triptan medicationsprochlorperazinerimegepant (Vydura)lactosepeanut or soyaother medicationsother substancesAre you able to take pills containing lactose? *YesNoP & SOur pharmacists source medication from a wide range of approved manufacturers to ensure we have a good supply available. Some manufacturers produce medication that isn’t suitable for people who suffer with peanut or soya allergies. Before starting your medication, it’s important to check the enclosed manufacturer’s leaflet to make sure the medication you’ve received is suitable for people with peanut or soya allergies. We also recommend checking with your local pharmacist.Please tick if you’d still like to proceed with your order.Please provide more details:Checkboxes *Please tick to confirm that you:fully understand the questions in this questionnaire and have answered honestly and truthfully fully understand the side effects of the treatment options, their effectiveness and alternative options, and are happy to continue with your requestconfirm and agree that any treatment prescribed for you is for your personal use only *I have read, understand and agree to AllCare Pharmacy Online Doctor's Privacy Policy. *Vydura (rimegepant) is a relatively new migraine treatment. It's a wafer that dissolves in the mouth, so it's good for anyone who is sick with their migraines.There are two ways that Vydura can be used; either for treating acute attacks as they happen, or to be taken regularly to prevent them happening in the first place. If you're treating an acute attack, take one 75mg tablet as needed. Anyone wanting to prevent attacks and having at least 4 migraine attacks per month, take one 75mg tablet every other day.If you have less than 4 attacks per month, you should not be using Vydura as prevention. See your GP for alternative preventative options instead. You can still use our treatments to deal with any acute attacks.NextWhat’s Your Birth Gender? *MaleFemaleName *FirstLastEmail *Phone *What’s Your Date of Birth? *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Select pharmacy for collection *674 Coventry Road, Small Heath, Birmingham, B10 0UU105 Barton Street , Gloucester, GL1 4HR267 Dewsbury Road, Leeds, LS11 5HZ41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RWNationwide DeliveryYesPreviousNextDo you agree and consent to the following? You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life- threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation. *Please confirm you understandPrivacy Policy *I have read, understand and agree to AllCare Pharmacy Online Doctor's Privacy PolicySubmit