Migraine Form · Submit

Welcome.

Welcome to Simple. where we work hard to make sure that helping you manage your migraines doesn't mean giving up more days to dark rooms and lost time with family or friends. What can we help with? * Secure Please select your main goal with Simple.

Tell us more.

How many migraine days do you have a month? * Secure This would be a headache accompanied by migraine symptoms such as throbbing pain, nausea, sensitivity to light or sound, or worsens with activity.

How many headache days do you have a month? * Secure This is just days with head pain, pressure or a mild headache.

Have you seen any changes in your headache patterns? * Secure Please let us know what your pattern was before, and how it's changed.

What medical diagnoses have been given to you by healthcare professionals you have seen? * Secure Please list all medical conditions, not just migraine diagnoses.

Medications.

What medications are you currently taking? * Secure This includes all medications, not just migraine medications. Please include dosage and frequency.

Is your migraine medication effective? * Secure Does this medication give you the results you want?

What side effects do you have with your current medication? * Secure How does this compare to other migraine medications you have taken before?

We're almost there.

Please let us know how long you have tried each of your migraine treatments and how effective they were. Also, be sure to use this space to let us know anything else that might be important. * Secure These details will help us learn more.

Please provide insurance information or if there is none, write n/a. * Secure If a medication is prescribed, it will be sent to the pharmacy with your insurance information.

Please provide your name. Secure

Please provide your date of birth. Secure This is needed for insurance and to approve medications.

Please provide the best number to contact you. Secure

Please provide your address so we know where to ship your medication. Secure Making things Simple. also means not driving around. We ship right to you.

One last thing.

Patient acknowledgment: I confirm that the information provided is accurate to the best of my knowledge and understand that the clinician may request additional testing before treatment. * Secure

I consent to my information being reviewed by a qualified healthcare provider for the purpose of evaluating my health concerns and determining action which may include prescription medication. * Secure

I consent.