Migraine Headaches

Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

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No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

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Unfortunately we cannot proceed with your request based on the information you have provided.

What symptoms have you been experiencing recently?*

If you've listed "other", please explain your symptoms:*

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for migraine headaches?*

Yes
No

How long ago?*

What medications were you treated with?*

Chlorpromazine
Nerve pain drugs
Triptan
Other

What type of nerve pain drugs?*

Topiramate
Amitriptyline

What type of Triptan?*

Sumatriptan
Frovatriptan
Rizatriptan
Zolmitriptan
Naratriptan
Almotriptan
Eletriptan
Naproxen/Sumatriptan

Describe the treatment plan:*

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

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No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

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No

Please list any medications, herbals, or supplements:*

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Migraine Headaches

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