First Name *

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Last Name *

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Phone Number *

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Email *

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Date of Birth DD/MM/YYYY *

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Postal Code *

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What was your gender assigned at birth? * Please select one… Female Male Other Prefer not to say

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Which racial or ethnic group(s) do you identify with?
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc.)

Another race or ethnicity

I prefer not to answer

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Has a doctor diagnosed you with migraine? * Please select one… Yes – I have been diagnosed with migraine No

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Have you been having migraine attacks for at least 1 year? * Please select one… Yes No

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At what age did your migraine symptoms begin? * Please select one... Before age 50 After age 50

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How many hours do your migraine attacks last when untreated or treated unsuccessfully? *
A migraine attack is a bad headache with some symptoms like sensitivity to light or sound, or nausea lasting at least 4 hours.
Please only enter number of HOURS.

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Considering the last 3 months, on average, how many migraine attacks did you have per month? * Please select one... 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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Considering the last 6 months, on average, how many days per month did you have a headache? * Please select one... 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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Are you currently using or have you ever used a triptan medication to treat migraine attacks? *
(Examples of triptans include:

• Almotriptan (AXERT®)
• Eletriptan (RELPAX®)
• Frovatriptan (FROVA®)
• Naratriptan (AMERGE®)
• Rizatriptan (MAXALT®)
• Sumatriptan (Imitrex®, Sumavel DosePro ®, Alsuma ™, and Zembrace® SymTouch®)
• Zolmitriptan (ZOMIG®))

Please select one... Yes No

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Have you been diagnosed by a doctor with any of these medical conditions? *

Inflammatory Bowel Disease (Crohn’s disease or ulcerative colitis)

Non-Alcoholic Fatty Liver

Cirrhosis

Dementia

Epilepsy

Unsure

None of the above

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Are you taking any medications for other health conditions? *
Please list them below or type ‘none’.

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What is the best day/time to reach you via telephone? *

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