About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Do you have any allergies?
If yes, please provide details
Are you the actual consumer of this medication?
If not, who is it for and how old are they? Please complete the consultation on the intended user's behalf.
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Can you relate to any of the following?
You have an underlying medical condition
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Do you have frequent or daily headaches despite the regular use of headache medication?
Do you have any heart or circulation problems?
If yes, please provide details
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
What is your biological gender?
Please select your option
Do you connscent to immeidtaely stop taking this prescription and seek medical attention right away if any of the following symptoms occur
Breathing that is slow or shallow.
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
Do you suffer from migraine attacks every day?
Have you been through menopause?
Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Do you suffer from any allergies?
If you do, kindly explain them below
Are you aware that we can only provide one codeine-containing medication per order?
Codeine-containing over-the-counter medications include:
Do you have any neurological problems?
Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
Do you experience visual disturbances or other neurological symptoms long after resolution of the headache?
Have you had a serious reaction or intolerable side effects to triptan products, antibiotics or any other medications before?
If yes, please describe the product and the reaction
Are you on any of the following medication?
Antibiotics.
Women only: Are you breast feeding?
Have you consulted a medical practitioner about your symptoms?
If you have, what was their recommendation?
Do you have any liver or kidney problems?
If yes, please provide details
For which duration have you been plagued by these symptoms?
Please select your option
Have you been told by your doctor that you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucosegalactose malabsorption)?
If yes, please provide details
Which symptoms do you intend to cure using Migraleve pink tablets?
Which symptoms do you intend to cure using Migraleve yellow tablets?
Has your doctor told you that you suffer from migraines?
Please provide details in this box here...
Are you a heavy smoker, or do you use nicotine substitution therapies?
Do you have high blood pressure?
Have you had a stroke or a mini-stroke?
Do you have a seizure disorder (e.g. epilepsy) or a history of seizures?
If yes, please provide details
Please provide details of any symptoms you experience
Please list all your current prescription medication including any medication you buy over the counter...
Please provide details of any recent or past medical history of note
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The Agreement
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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Women only: Are you pregnant or is there a possibility you may be pregnant?
Women only: are you currently breast-feeding?
How frequently do you get migraines?
Please select your option
Do any of the following symptoms accompany your headaches:
They only occur as a result of a brain damage.
Do you agree to the following?
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