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Male Female Other

    1 - How long ago did your current headaches begin?*


    • 2 - When was your most recent headache?*


    • 3 - At what age did you have your first headache?*


    • 4 - Are you ever completely free of pain?*

  • Yes
    No

    • 5 - Do you have more than one type of headache? Please describe them each separately.*


    • 6 - How many headaches do you have each month?*


    • 7 - How long do the headaches last?*


    • 8 - How would you describe the pain of your most serious headaches?*

  • Throbbing
    Pulsating
    Dull aching
    Pressure-like
    Sharp
    Stabbing
    Electric-like
    Vise-like

    • 9 - When you have a headache (and possibly after), does your scalp and face become sensitive to touch — and do you avoid putting on glasses, jewelry or combing your hair?*

  • Yes
    No

    • 10 - "Do your headaches occur on any particular day of the week or time of day? "*


    • 11 - Do you experience any warning signs before the start of a headache? If so, please describe them.*


    • 12 - What parts of the head do you experience pain?*

  • Front of head, toward either the left or right side
    Front of head, in the center
    Dull aching
    Side of head, near the top
    Side of head, near the temples
    Rear of head, near the top
    Rear of head, near the neck
    Top of head

    • 13 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


    • 14 - Do you take any medicines, vitamins, or supplements?


    • Please list them here.

    15 - Please list any allergies you have.


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    16 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?


    • 17 - Do you have a preferred treatment?*

  • No preference
    Amytriptyline|(Generic Elavil®)|$30 per month, $60 every 3 months
    Naproxen Sodium Tablet|(Generic Naprosyn®)|$30 for 30 treatments
    Propranolol ER|(Generic Inderal LA®)|Starting at $20 per month
    Sumatriptan Tablet|(Generic Imitrex®)|$35 for 9 treatments
    Topiramate|(Generic Topamax®)|$30 per month, $60 every 3 months
    Divalproex Sodium ER|(Generic Depakote ER®)|$30 per month, $60 every 3 month
    • Don't worry if you're not sure. Your doctor will help you pick the best one for you.

    18 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

    19 - Do you have a preferred dose or strength?


(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

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