Assessment

Have you been diagnosed with any of the following?

• Heart disease or heart problems such as narrowing of the arteries (ischaemic heart disease) or chest pains (angina), or have already had a heart attack
• Stroke or a mini-stroke (also called a transient ischaemic attack or TIA)
• High blood pressure
• Coronary Vasospasm (including Prinzmetal’s angina)
• Wolff-Parkinson-White Syndrome (a type of abnormal heartbeat)
• Peripheral Vascular Disease
• Previous Gastrointestinal or Splenic infarction
• Ischaemic Colitis
• Epilepsy or history of seizures
• Liver / digestive system problems
• Kidney problems
• Allergy or sensitivity to antibiotics called sulphonamides (e.g. trimethoprim)
• Any serious medical condition which may require immediate hospitalisation

Are you currently pregnant, planning to become pregnant or breastfeeding?

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?

Please give more details

Do you have any known allergies to any medicines or substances?

Please give more details

Do you have any other health problems or conditions that you think we should know about? e.g. recent or major operations, G6PD, mental illness, neurological conditions etc.

Please give more details

Have you had your eyes tested in the last 12 months?

Do you wear glasses or contact lenses?

Please enter your date of birth

Have you previously been diagnosed with migraine by a GP and been prescribed a Triptan medicine (Sumatriptan, Zolmitriptan or Rizatriptan)?

Have your migraines gotten worse recently?

Please provide more information below.

Are you allergic to any of the following?

• Sumatriptan (Imigran)
• Sulphonamides (Antibiotics)
• Ergotamine (rare prescription medicine for migraine)
• Other triptan medicine (Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan or Zolmitriptan)

Please provide more information below.

Do you, or have you ever taken an MAOI antidepressant or any other form of antidepressant?

Please give more details

Do you experience pain or a feeling of pressure in the chest for more than a few minutes after taking a Triptan (Sumatriptan, Zolmitriptan, Rizatriptan)? Note: This is very rare but could be symptoms of a heart attack.

Please provide more information below.

I am aware of Serotonin Syndrome and I will seek medical attention if I have any of the following:

• Gastrointestinal symptoms including diarrhoea and vomiting.
• Nervous system symptoms including overactive reflexes and muscle spasms.
• Other Serotonin Syndrome symptoms including fever, sweating, shivering, clumsiness, tremors or irregular heartbeat, confusion or other mental changes.

If you experience more than 3 migraines a month you need to see your GP

We strongly advise that you inform your GP of any medication you receive.

Would you like us to inform your GP of medication you receive from Rightdose?

Please enter your:

• Full Name
• Date of Birth
• Your registered home address with your GP

Please enter your:

• GP Surgery Name
• GP Surgery Address
• GP Surgery Email
• GP Surgery Contact Number

I confirm:

• I am over 18 years old
• The medicine ordered is for my sole use only
• I take responsibility to inform my own regular doctor of the online assessment or any changes in my circumstances
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages
• I have answered all the questions truthfully
• I agree to the Rightdose online pharmacy privacy policy and terms and conditions