Migraleve questionnairenew2.ai

Migraleve Ultra Migraine Questionnaire
Please answer the questions below by ticking the boxes that apply to you.
If you are not sure about any of the questions, leave them blank and the pharmacist will help you.
About you…
Note to pharmacist: to be used with Migraine Questionnaire Guidance If you are female, are you pregnant, do you think you might be pregnant, or are you breast-feeding? Have you had fewer than 5 migraines in the past? Did you have your first ever migraine within the last year? If you have answered ‘Yes’ to any of these, please speak to the pharmacist before going further.
About your migraines…
1. Has your doctor given you any medicines for migraine? 2. In the last three months, has a headache interfered with your activities on at least one day? When you have a headache, do you feel nauseous (sick)? When you have a headache, does light bother you? 3. Roughly how many migraine attacks do you have each month? How long does the headache part of your migraine usually last (as opposed to other migraine symptoms) if you don’t take any medicine, or if it doesn’t work? How many days a month do you usually have a headache of any type (including a In between your migraine attacks, do all the symptoms of your migraine go away? Do your migraines follow a broadly similar pattern each time? 4. When you have a migraine headache, do you get any other symptoms apart from nausea/sickness or sensitivity to light or sound? If yes, please write down these symptoms.
5. Did the symptoms of migraine occur for the first time over the age of 50? Turn over
If you want to buy Migraleve Ultra again, simply bring this Treatment Card to your Pharmacy.
I have completed the Migraine Questionnaire and my pharmacist has agreed I am suitable for Migraleve Ultra For further information go to www.migraine-advice.com Pharmacy Stamp
Pharmacist initials.
About your medical history…
6. Please write down the names of, and reasons for, taking any medicines you are currently on (prescription medicines from your doctor, including the contraceptive pill, as well as medicines, supplements or herbal remedies you may have bought yourself ). If you are unsure of the names, please speak to the pharmacist.
Has your doctor told you that you have or have had any of the following? High blood pressure, or are you taking medication for high blood pressure? (You should get this Heart disease including heart attack, angina (heart pain in the chest brought on by exercise or exertion), heart failure or an irregular heart beat.
Stroke or mini stroke (transient ischaemic attack, TIA).
Peripheral vascular disease (for example, poor blood flow to the legs with pain on walking).
Epilepsy or you are prone to having fits.
Have you ever had an allergy or bad reaction to Imigran or Migraleve Ultra (sumatriptan) or sulphonamide antibiotics, eg Septrin (co-trimoxazole)? Do you have a family history of early heart disease: either your father or brother had a heart attack or angina before the age of 55or your mother or sister had a heart attack or angina before the age of 65? Has your doctor told you that you have diabetes? Have you been told that you have high cholesterol? Do you regularly smoke more than 10 cigarettes per day? Customer Name .
Date of assessment .
I give consent for the pharmacist to keep this form
Customer signature .
Pharmacist signature

Source: http://www.migraleve.co.uk/pdf/Migraleve_Questionnaire.pdf