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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This refers to your biological gender
Male
Female

Height should be above 1 ft 10 inches

If so, please tell us how many units per day. You can use the following as a guide:- Pint of beer = 3 units- A can of beer = 2 units- A large glass of red wine = 3 units

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

Use the following as a guide:Low = Under 90/60Normal = Between 90/60 and 140/90High = Over 140/90


If you cannot, please provide more information

If you do, kindly explain them below

Please list all your current prescription medication including any medication you buy over the counter.

If so, please provide more details


If so, please provide more information

Please provide more information of the medication being used if any.



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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If you are male, answer No

If you are male, answer No

If so, please tell us more...

Please select your option
They started recently (less than 6 months)
About 6-12 months
3 years at most
They've lasted more than 3 years

Please select your option
Everyday
Some days
Every week
Every two weeks
Each month
Some months
Every few months

- They only occur as a result of brain damage. - In 5 minutes or less, they reach their peak intensity. - They occur in conjunction with a loss of speech, feeling, strength, or awareness. - They appear in conjunction with a fever or stiff neck. - They're accompanied by tenderness in the area of your temples. If you do, please be as specific as possible about your symptoms.

Please select your option
Simple analgesics such as paracetamol or ibuprofen
Codeine-based analgesics such as Co-codamol
A triptan such as Sumatriptan/Imigran
Propranolol immediate-release tablets
Propranolol prolonged-release capsules
None of these

If you are male, please select No

If so, what drugs were used and how successful were they?

If so, please describe



Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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- You declare that I have answered the above truthfully- You will read the patient information leaflet before taking your medication (if prescribed)- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.