Patient Information and Instruction Form
Patient name (insert 1AA)
Date of office visit (insert 1AAA)
You have been diagnosed with (insert 1A)
You have been prescribed the following treatment plan:
A. Acute treatment: At the earliest sign of a migraine take (insert 1B). If you do not feel pain relief by (insert 1C) hours, take (insert 1D).
B. Rescue treatment: If you do not feel relief by (insert 1E) hours since your last dose of medication, you can take (insert 1F).
C. Preventive treatment: You have also been prescribed a medicine that will decrease the frequency and severity of your headaches.
a. Take (insert 1G) for (insert 1H).
b. After (insert 1H), you should increase the dose to (insert 1I) for (insert 1J).
c. After (insert 1J), you should increase the dose to (insert 1K).
IMPORTANT THINGS TO KNOW:
1. After treating (insert 1L) headaches, please call our office if you do not get pain
relief from your acute medications.
2. If you have been prescribed a preventive medication, please call our office if you
do not see an improvement in your headaches after (insert 1M). (It is not unusual
for improvements in headache status to progress slowly over 4-12 weeks.)
3. If you experience any unusual sensations or adverse events, please call our office.
4. You will need to call our office to have your prescription refilled regularly. Please
call our office during daytime office hours as we are unable to refill selected
prescriptions when the office is closed.
We have rescheduled your follow-up appointment for (insert 1N). It is important to return to the office for this appointment on (insert 1O) so we can make sure the medications are working for you. This is also a time when we can make changes to your treatment plan.
Did you know… you can reduce your headaches by maintaining regular sleeping patterns, limiting caffeine, and exercising regularly. One way to help you do this is to keep a written note or diary that details the date of the headache, treatment taken, response to treatment and any recognized triggers.