If you are male, answer No

If you are male, answer No

If so, please tell us more...

Please select your option

Please select your option

- 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

If you are male, please select No

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

If so, please describe

- 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.