Migraine Relief – Reddydoc

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Email *

First Name *

Last Name *

Phone

Date of Birth *

Confirm Date of Birth *

Check to confirm date of birth

Gender *

Weight *

Height *

Race

Other Race

Marital Status

Who is the patient? *

What disease are you suffering from? *

Select Your Location *

Let's match you with an authorized medical professional in your state.

Consent 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 information

Treatment authorization with informed consent *

I give my permission to ReddyDoc's medical personnel to evaluate my medical history and provide help (synchronous or asynchronous) healthcare to me, the patient.
I authorize ReddyDoc to prescribe another medication if my chosen or preferred prescription is potentially harmful, unsafe, regulated, risky, or interacts with another medication I'm taking, or has an adverse drug reaction.
I am aware that ReddyDoc will decline to treat individuals suffering from serious or complicated ailments and will cancel their consultations.
I consent that ReddyDoc will provide online medical services based on the medical history I provide. As a result, I take sole responsibility for any adverse effects caused by supplying inaccurate, misleading, or incomplete information.
I am aware that there could be a slight chance of misdiagnosis as there is no in-person examination.
If my symptoms worsen or do not improve soon, I agree to call 911 or see a doctor for a face-to-face examination.

I understand that if my medical practitioner requires additional information or if I provide insufficient medical history, the evaluation may be delayed.
I understand that the consultation fee does not cover the cost of the medication if I choose to pick up my prescription (s) from a pharmacy; I remain responsible for payment to that pharmacy.
I've been informed that I can use my insurance to make payments for my prescription medication at the pharmacy.
I accept that if my insurer is unable to pay for the required test or medication, or if the cost of the drug is exorbitant, I must email ReddyDoc to request an alternate medication or out-of-pocket (self-pay) alternative.

Do you have a life-threatening symptom or a medical emergency? *

Yes
No life-threatening symptoms

Unfortunately we do NOT treat life-threatening conditions online. Please call 911

Are you focused and alert? *

You must be focused and aware.

Are you allergic to any medications? *

No, there are no medication allergies (NKDA).
Yes

What drugs do you have an allergy to? *

Do you have any underlying medical issues? *

I have no chronic medical or psychiatric issues
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other Condition

List any further health issues you may have. *

Type of heart issue *

Coronary Artery Disease (CAD) or heart attack
Heart Valve Disease
Arrhythmias or abnormal heartbeat
Heart Failure or CHF
Congenital Heart Disease
Cardiomyopathy (Heart Muscle Disease)
Pericardial Disease
Other

List other heart conditions that you have *

What's your average blood pressure reading? *

Normal (Less than 140/90)
Elevated (Less than 160/100)
Uncontrolled (Over 160/100)

Type of liver disease

Type of kidney disease *

Kidney stone
Polycystic Kidney Disease
Kidney infection or cyst
Nephritis or nephropathy
Kidney cancer
Elevated creatinine or low GFR
Solitary or Single-functioning Kidney
Other

List other kidney disease *

How 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)

Last thyroid test *

Normal TSH level in the last 12 months
Elevated TSH (or low T4 or T3) level
Low TSH (or low T4 OR T3) level
No thyroid lab test in the last 12 months
I have symptoms of abnormal thyroid disorder

Select applicable psychiatric condition *

Depression
Anxiety
Panic disorder
Bipolar or mood disorder
Schizophrenia or psychosis
PTSD
Eating disorder
OCD
Other

Other condition

Are you currently taking any medication? *

Enter medication name *

Medication Disclosure Clause *

I hereby certify that I am NOT currently taking any medication including OTC or supplements, and agree to indemnify and hold ReddyDoc and its employees harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication or any other vital medical information

Select Relevant Social History *

Non-smoker
Drink Coffee multiple times a day
Current smoker (Vape, cigarette or tobacco)
Former cigarette or tobacco use
Prescription drug addiction
Alcohol addiction

When was your last in-person visit to the doctor? *

Within the past three(3) months
Within the last three (3) to six (6) months
Within the last six (6) to twelve (12) months
More than a year ago
Never met a doctor in person

Are you the patient in need of medical treatment? *

Yes, I'm the patient in need of treatment
I'm filling out this consultation on behalf of the patient

STOP! PATIENT ALONE MUST COMPLETE THIS FORM

What's your average blood pressure reading? *

Normal (110-140/60-90)
Low (lower than 100/60)
High (over 160/90)

When were you first diagnosed with migraine? *

Recently diagnosed (less than a year)
Diagnosed over a year ago
I have NEVER been diagnosed with migraine

What's the primary reason for this consultation? *

Acute migraine treatment
Migraine prevention (Prophylaxis)
Dizziness or lightheadedness
Sinus headache
Elevated blood pressure
Facial or jaw pain
Unknown cause of headche

STOP! This is a consultation for migraine only. Contact us at provider@www.condition.reddydoc.com for help

Which of these apply? *

I do NOT have a migraine headache at this time
I'm experiencing mild to moderate headaches
I have a severe headache
I have a thunderclap headache
I'm experiencing the worst headache of my life

STOP! We do not treat severe cases. Contact us at provider@www.condition.reddydoc.com for help

Do you have any of these conditions? *

Migraine
Seizure disorder
Stroke
Glaucoma
Heart attack
None of the above medical conditions
Other

List any additional health issues. *

List any other medical conditions *

Please describe the nature of your migraines *

I experience occasional migraines
I experience daily (or near-daily) headaches of low to moderate severity
I experience frequent or long lasting migraine headaches
I experience migraine attacks that cause significant disability or diminished quality of life despite appropriate
Menstrual migraine
None of the above

Which of the following describes your headache *

Throbbing or pulsatile quality
Affecting both side of the head (bilateral)
Affecting one side of the head (unilateral)
Neck pain
With Aura
Without Aura
None of the above

Do you have any of these associated symptoms? *

Dizziness
Weakness
Neck stiffness
Fever
Vomiting
Nausea
Sensitivity to light and sound
None of the above symptoms

STOP! This is a sign of severe headache. Contact us at provider@callondoc.com for help

How often do you experience migraine headaches in a month? *

Less than 14 days per month
More than 15 days per month

Do you currently have a headache that is significantly different from prior headaches? *

I'm experiencing a typical form of migraine
This episode is different from prior headaches
I don't have a headache at this time

Are you experiencing any of these neurologic symptoms? *

Facial drooping
Weakness or paralysis of any part of the body
Speech difficulty or slurred speech
Confusion or behavioral changes
Memory loss
Fainting or loss of consciousness
Seizures
None of the above symptoms

STOP! You're not a candidate for online treatment. See your doctor immediately

Briefly describe the last visit with your doctor (regarding your migraine) *

What medication(s) are you currently taking for headache relief? *

To prevent overuse, acute therapy are limited to a 10-day supply per month

Preferred Treatment Plan *

Acute migraine headache treatment
Migraine prevention (Prophylaxis)

Which of these prophylaxis would you like us to prescribe? *

Amitriptyline
Topiramate to minimize future episodes
I'll let the doctor decide

Select Preferred Rx Refill Option *

($39.99)One month supply with one refill
($49.99)90-day supply (3 month supply)
($89.99)6 months (90-day supply with ONE refill)

Topiramate or Amitriptyline Warning *

I understand that I cannot abruptly discontinue Topiramate or Amitriptyline to prevent rebound effects

Blackbox Warning *

I have been informed to avoid Amitriptyline if I have glaucoma, had a heart attack or have taken MAOIs within 14 days

Precaution *

I agree to avoid performing tasks which require mental alertness (eg, operating machinery or driving) while taking Topiramate or Amitriptyline

Medication side effect *

I have been informed of the side effects of Topiramate and Amitriptyline, which includes confusion, psychomotor slowing, difficulty with concentration, suicide tendency, behavioral change, hypotension, memory, speech or language problems, psychiatric disturbances, sedation, somnolence and fatigue

Important Information: We do not include the cost of medications in the consultation price. *

I am aware that even if my insurance does not cover a particular prescription, I will still need to pay for it at my local pharmacy.

Follow-up agreement *

I understand and agree to follow up with a doctor in-person or go to the ER immediately if my symptoms persist or worsen

Given 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 needed
I have an upcoming appointment with my doctor

When is your next doctor's appointment? *

Upload clinically relevant pictures and lab report (Optional)

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