Migraine Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 56Email *NextFirst Name *Last Name *PhoneNextDate of Birth *Check to confirm date of birth *Check to confirm date of birthGender *MaleMaleFemaleWeight *Height *4' 0''4' 0''4' 1''4' 2''4' 3''4' 4''4' 5''4' 6''4' 7''4' 8''4' 9''4' 10''4' 11''5' 0''5' 1''5' 2''5' 3''5' 4''5' 5''5' 6''5' 7''5' 8''5' 9''5' 10''5' 11''6' 0''6' 1''6' 2''6' 3''6' 4''6' 5''6' 6''6' 7''6' 8''6' 9''6' 10''6' 11''7' 0''7' 1''7' 2''7' 3''7' 4''7' 5''7' 6''7' 7''7' 8''7' 9''7' 10''7' 11''RaceSelectAlaska NativeAmerican IndianAsianBlack/African AmericanHawaiian or Other Pacific IslanderHispanicWhiteOtherOther *Marital StatusSelectSingleMarriedDivorcedSeparatedPreviousNextWho is the patient? *Myself (the patient)Myself (the patient)Pediatric (2-17 yrs old)FriendPreviousNextWhat disease are you suffering from? *PreviousNextSelect Your Location *TexasTexasKansasGeorgiaFloridaNevadaMississippiLouisianaAlaskaSouth CarolinaSouth DakotaAlabamaArkansasNew MexicoLet's match you with an authorized medical professional in your state.PreviousNextConsent to use information *We kindly request your consent to use the information collected during your interactions with our platform, to ensure transparency and data protection. Visit our privacy policy for more informationNextAuthorization to administer treatment and informed consent *I thus give my consent for the medical staff at ReddyDoc to examine my medical background and provide telemedicine (synchronous or asynchronous) healthcare to me, the patient.In the event that my chosen or preferred prescription is possibly hazardous, unsafe, controlled, risky, interacts with another medication I'm taking, or has an adverse drug reaction, I thus give ReddyDoc permission to prescribe an alternate drug.According to what I've been told, telemedicine services are only appropriate for mild to moderately complex medical requirements. I am aware that ReddyDoc will refuse to treat patients with serious or complex diseases and will cancel their appointments.I am aware that, in the absence of a physical examination, ReddyDoc will deliver online medical services based on the medical history I submit. I thus accept full responsibility for any injury or losses that may result from providing false, misleading, or incomplete information.I am aware that using telemedicine has a risk of misdiagnosis because there is no physical exam or in-person evaluation.I consent to phone 911 or follow up with a doctor for an in-person assessment if my symptoms get worse or don't get better quickly.PreviousNextTerms of use *I am aware that if my medical practitioner needs more information or if I submit insufficient medical history, the process could be delayed.I am aware that the consultation charge does not cover the cost of the medicine if I decide to pick up my drug(s) from a pharmacy; I will still be responsible for paying that pharmacy.I've been told that I can use my insurance to pay for my medication at the drugstore.I understand that I must email ReddyDoc to request an alternate medication or out-of-pocket (self-pay) options if my insurer is unable to pay for the required test or medication, or if the cost of the medication is prohibitive. I've been told that insurance restrictions or prescription costs are not acceptable justifications for issuing a refund. The patient is financially accountable for their prescriptions and medical services.PreviousNextDo you have a life-threatening symptom or a medical emergency? *YesNo life-threatening symptomsWe do not, unfortunately, treat life-threatening disorders. Please call 911PreviousNextAre you focused and alert? *YesNoYou must be focused and aware.PreviousNextAre you allergic to any medications? *No, there are no medication allergies (NKDA).YesWhat drugs do you have an allergy to? *PreviousNextDo you have any underlying medical issues? *I have no chronic medical or psychiatric issuesHeart diseaseHypertensionLiver diseaseKidney diseaseDiabetesHigh cholesterolThyroid disorderPsychiatric conditionHIV/AIDSOther ConditionList any further health issues you may have. *PreviousNextType of heart issue *Coronary Artery Disease (CAD) or heart attackHeart Valve DiseaseArrhythmias or abnormal heartbeatHeart Failure or CHFCongenital Heart DiseaseCardiomyopathy (Heart Muscle Disease)Pericardial DiseaseOtherList other heart conditions that you have *PreviousNextWhat is the average reading of your blood pressure? *Normal (Less than 140/90)Elevated (Less than 160/100)Uncontrolled (Over 160/100)PreviousNextType of liver diseasePreviousNextType of kidney disease *Kidney stonePolycystic Kidney DiseaseKidney infection or cystNephritis or nephropathyKidney cancerElevated creatinine or low GFRSolitary or Single-functioning KidneyOtherList other kidney disease *PreviousNextHow stable or controlled is your diabetes? *Well controlled (Glucose below 150 or Hba1c less than 8)Somewhat controlled (Glucose below 200 or Hba1c less than 9)Uncontrolled Diabetes (Glucose over 200 or Hba1c over 9)PreviousNextLast thyroid test *Normal TSH level in the last 12 monthsElevated TSH (or low T4 or T3) levelLow TSH (or low T4 OR T3) levelNo thyroid lab test in the last 12 monthsI have symptoms of abnormal thyroid disorderPreviousNextSelect applicable psychiatric condition *DepressionAnxietyPanic disorderBipolar or mood disorderSchizophrenia or psychosisPTSDEating disorderOCDOtherOther conditionsPreviousNextAre you currently taking any medication? *NoYesEnter medication name *PreviousNextSelect Applicable Surgical History *No surgical pastAppendectomyBreast augmentationC-sectionGallbladder surgeryHysterectomyHernia repairMastectomyOrthopedic surgeryTonsillectomyOther surgeryList any more operations you had in the past. *PreviousNextSelect Relevant Social History *Non-smokerDrink Coffee multiple times a dayCurrent smoker (Vape, cigarette or tobacco)Former cigarette or tobacco usePrescription drug addictionAlcohol addictionPreviousNextLast visit to a doctor for in-person visit? *In the last 3 monthsIn the last 3 to 6 monthsin the last 6 to 12 monthsNever been to a doctor in personPreviousNextWhat is the average reading of your blood pressure? *Normal (110-140/60-90)Low (lower than 100/60)High (over 160/90)PreviousNextWhen were you first diagnosed with migraine? *Recently (within the past year) diagnosedDiagnosed over a year agoI have NEVER been diagnosed with migrainePreviousNextWhat's the primary reason for this consultation? *Acute migraine treatmentMigraine prevention (Prophylaxis)Nasal headacheUnsteadiness or faintnessIncreasing blood pressureJaw or facial painHeadache of unknown cause STOP! This is a consultation for migraine only. Contact us at provider@www.condition.reddydoc.com for helpPreviousNextWhich one of these fits? *I am experiencing a migraine headache.I have a thunderclap headacheMy headaches range from mild to moderate.My head hurts so much.I have never had a headache this bad in my life.STOP! We do not treat severe cases. Contact us at providerreddydoc.com for helpPreviousNextDo you suffer from any of these ailments? *MigraineEpilepsy disorderStrokeGlaucomaChest painNone of the medical disorders listed aboveOtherList any other medical conditions PreviousNextPlease describe the nature of your migraines *I occasionally get migraines.I have low to moderate intensity headaches daily (or nearly daily).I frequently get or have persistent migraine headaches.Despite receiving appropriate treatment, I frequently get migraine attacks that significantly impair my quality of life.Migraine at a periodNone of the aforementionedPreviousNextWhich of these best describes your headache? *Pulsating or throbbing headacheBoth sides of the head are affected (bilateral)Having only one side of the skull affectedA sore neckUsing AuraAbsent AuraNone of the aforementionedPreviousNextDo you experience any of the related symptoms? *DizzinessWeaknessNeck stiffnessFeverVomitingNauseaSensitivity to light and soundNone of the above symptomsSTOP! This is a sign of severe headache. Contact us at provider@www.condition.reddydoc.com for helpPreviousNextHow many times a month do you have a migraine headache? *Less than 14 days per monthMore than 15 days per monthPreviousNextDo you currently suffer from a headache that is notably different from headaches in the past? *I have a regular migraine right now.This headache episode is distinct from earlier headaches.Right now, I don't have a headache.PreviousNextDo any of these neurological symptoms apply to you? *Facial slacknessWeakness or paralysis in any body componentSlurred or difficult to understand speechConfusion or alterations in behaviorNo memoryLoss of awareness or faintingSeizuresThere are no symptoms mentioned above.STOP! You're not a candidate for online treatment. See your doctor immediatelyPreviousNextDescribe your most recent doctor's appointment in detail as it relates to your migraines.PreviousNextWhat drug(s) are you currently taking to treat your headaches?PreviousNextA 10-day supply of acute therapy is all that is allowed every month to prevent overuse. *Treatment for severe migraine headachesPreventing migraines (Prophylaxis)PreviousNextWhich drug from this list would you like us to recommend to you? *Sumatriptan (Imitrex) (15 tabs/ month)Diclofenac 75 mg (15 tabs/ month)Naproxen 500 mg (15 tabs/ month)Rizatriptan (Maxalt) (15 tabs/ month)Zolmitriptan (Zomig) Nasal sprayI'll let the doctor decidePreviousNextWhich one of these preventative measures would you like us to recommend?AmitriptylineTopiramate to minimize future episodesI'll let the doctor decidePreviousNextChoose your preferred prescription refill option. One refill and a one-month supply3 month supply for a 90-day supply6 months (one refill for a 90-day supply)PreviousNextTopiramate or Amitriptyline Warning *I am aware that in order to avoid rebound effects, I cannot stop taking Topiramate or Amitriptyline suddenly.Blackbox Alert *I was told to stay away from Amitriptyline if I had glaucoma, had a heart attack, or used MAOIs within the previous 14 days.Precaution *I acknowledge that taking topiramate or amitriptyline should not be combined with activities that call for mental clarity, such as operating machinery or operating a vehicle.Adverse effect of medication *I've been made aware of the negative effects of topiramate and amitriptyline, which include disorientation, psychomotor slowdown, difficulties concentrating, a propensity for suicide, behavioral changes, hypotension, memory, speech or language issues, psychological abnormalities, drowsiness, somnolence, and fatigue.Follow-up agreement *I understand and agree to follow up with a doctor in-person or go to the ER immediately if the patient's symptoms persist or worsenPreviousNextImportant Disclosure: I pay for prescription drugs *I am aware that the cost of the medication at my pharmacy is still mine to pay.PreviousNextDo you have any additional details you'd like to present to the doctor today?YesNoPreviousNextDo you have any further details you would like to present to the doctor today? (Optional)PreviousNextGiven the limitation of telemedicine, we encourage an in-person follow-up if your medical concerns do not resolve after a telemedicine visit. *I agree to follow-up for an in-person re-evaluation with a local doctor as neededI have an upcoming appointment with my doctorWhen is your next doctor's appointment? *PreviousNextLeave a comment or feedback (Optional) *PreviousNextSupplemental Service Disclosure *We prescribe FDA-approved medications and follow evidence based medical guidelines. In some cases, the initial medication may not completely eradicate your symptoms or cure the infection. In this situation, similar to other clinics and doctor's offices, the patient is responsible to pay for the follow-up visit and repeat treatment.I have been informed that it's my responsibility to handle prescription medication with care and store it in a safe environment. There's an additional fee to reissue lost or misplaced medications.I understand that there is a processing charge of $20 when a request is made for an excuse note or doctor's letterI understand that there's a $50 surcharge when a request for prior authorization or peer to peer review is required by your insurance or payerPreviousNextRefund Policy TermsI am aware that I have a full refund option at any point before ReddyDoc sends my prescription. Our consultation charge is no longer refundable once a medical professional has finished your treatment plan, submitted your prescription to your pharmacy, requested a test, or fulfilled your request.We aim to finish every consultation in under two hours. However, insufficient medical data, technical issues, or a high patient load may cause the turnaround time to be prolonged. Be prompt if you must cancel due to delays. If your request for a refund is made after we have sent your prescription to the pharmacy or finished the treatment plan, the consultation fee is NOT refundable.I am aware that the consultation cost is non-refundable in the event that my body does not respond to therapy or if the prescribed medicine does not entirely cure my disease or eliminate all of my symptoms. You are welcome to submit a second consultation for review.PreviousNextWould you wish to offer a Power of Attorney or an Emergency Contact? *Yes, I want to add a power of attorney or an emergency contact.No! Please under no circumstances disclose my medical information to my relatives or friends.PreviousNextEnter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *PreviousNextDo you want to give the person who handles emergencies access to your medical records? *Yes! I hereby authorize ReddyDoc and its staff to provide my emergency contact with access to my medical records.No! I DO NOT authorize anyone to access my medical record or act on your behalf other than ReddyDoc, its designated agents, and employees.PreviousNextEnter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *PreviousNextPharmacy Name *Pharmacy Address *Pharmacy Phone *PreviousNextBilling Address *Address Line 1Address Line 2CityState / Province / RegionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePreviousNextConsultation feePrice: $34.99Stripe Credit Card *Submit