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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 - How many headaches do you have each month?*


  • 5 - How long do the headaches last?*


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

  • Throbbing
    Pulsating
    Dull aching
    Pressure-like
    Sharp
    Stabbing
    Electric-like
    Vise-like
  • 7 - 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
  • 8 - Which of these factors seem to contribute to your headaches?*

  • Exercise
    Stress
    Relaxation after stress
    Hormonal changes or periods
    Change in weather
    Alcohol
    Bright light or glare
    Odors
    Smoke
    Noise
    Lack of sleep
    Too much sleep
    Hunger
    Food additives
    Certain foods
  • 9 - Do your headaches occur on any particular day of the week or time of day? *


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


  • 11 - 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
    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
  • 12 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


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


  • Please list them here.

    14 - 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.

    15 - Please enter preferred pharmacy information.*


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

(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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