Pediatric Migraine

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

Who are you considering this study for? *

My Child

The Child I Care For

Other

First Name of Child/Teen *

Last Name of Child/Teen *

Date of Birth of Child/Teen *

Zip Code or Postal Code where the Child/Teen lives *

This helps us match them to the closest research site

What is the Child/Teen's assigned gender at birth? *

Female

Male

Prefer not to say

Does the Child/Teen suffer from migraine headaches? *

Yes – migraines

No

Has the Child/Teen been experiencing migraine headaches for at least 6 months? *

Yes - 6 or more months

No

In a typical month, how many days does the Child/Teen have a migraine headache? *

If the Child/Teen does not treat their migraine (for example, does not take medication), do their migraine headaches usually last at least 3 hours? *

Yes

No

Unsure

Has the Child/Teen ever taken any medication to treat or prevent their migraine headaches? *

Yes

No

Unsure

These may include Acetaminophen (Tylenol), Ibuprofen (Advil, Advil Migraine, Motrin), Naproxen (Aleve), Aspirin or medications prescribed by your doctor for migraine.

Has the Child/Teen been diagnosed(by a doctor) with any other medical conditions? *
(For example: Cancer, HIV, Hepatitis B, Hepatitis C, epilepsy, seizures, stroke, liver disease, Raynaud’s disease, diabetes, cardiovascular disease, psychosis, schizophrenia).

Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

Is the Child/Teen currently taking any medications for their health conditions? *
Please list them here or write 'none'.

How much does the Child/Teen weigh in Lbs (pounds)? *

Which racial or ethnic group(s) does the Child/Teen identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

Please provide your contact details so a member of the research team can reach you.
First Name of caregiver/parent to contact *

Last Name of caregiver/parent to contact *

Phone Number of caregiver/parent to contact *

Email of caregiver/parent to contact *

What is the best day/time to reach you via telephone (we know you are busy)? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

Yes No

If you are under the age of majority (the age at which a person becomes an adult and has full legal rights and responsibilities), you should not directly enter any information, and your legal parent or guardian should give their consent and enter this information on your behalf. If you are under the age of 13 (or 16 if you are in California or in Europe), and we become aware that you provided this information, rather than a parent or guardian, we will delete such information.

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

Child Migraine Treatment Studies

Help us research new investigational medication to treat kids and teens struggling with migraines.

Participation overview:

Clinical trial participants must:

What happens if I fill out the questionnaire?