Medical Information Sheet
Medical Information Sheet
|PATIENT NAME, | |
|SEX, AGE | |
|PHYSICIAN |Name and address |
| | |
| |Telephone +81(0) |
| |Fax +81(0) |
| |E-mail |
|MEDICAL DATA: |Migraine with aura |
|DIAGNOSIS in details |Migraine without aura |
|(including vital signs) |Cluster headache |
| | |
| | |
| |Date of diagnosis |
|He or She needs: |
|Sumatriptan (Imigran) self-injection kit when the intractable pain comes out. This kit includes plastic injecter (like insulin shots) and |
|some boxes of medicine. |
|No other medication could be effective for his (or her) pain. |
|Sumatriptan (Imigran) 20mg nasal spray for the mild pain relief. |
|Sumatriptan (Imigran) 50mg tablet for the mild pain relief. |
|( ) for the mild pain relief. |
| |
| |
|Specify more details, if necessary. |
| |
| |
| |
|Date: |
|Place: |
|Physician’s name: |
| |
|Signature: |
................
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