Fields marked with an * are required.

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. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. 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.

Do you consent to the collection and processing of your personal data (including information about your health, race and ethnicity (as applicable); including disclosure to our Research Partners) for the purpose of recruitment into clinical research studies? *

Yes

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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 MM/DD/YYYY *

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Zip Code or Postal Code *

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Are you Male or Female? Please select one... Female Male Prefer not to say

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Have you been told by a doctor that you have Migraine? * Please select one... Yes – I have 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? *

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Thinking back over the past months, what is the average number of migraine attacks you have experienced per month? * Please select one... 0-1 migraines 2-5 migraines 6-8 migraines 9-12 migraines 13-16 migraines 17+ migraines

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Have you been told by your doctor that you should not use Triptans for medical reasons (e.g., hypertension, heart attack, stroke/TIA, Angina etc.) or a hypersensitivity to Triptans? * Please select one… Yes No

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How many of the below Triptan medications have you tried? *

• Almotriptan (Axert)
• Eletriptan (Relpax)
• Frovatriptan (Frova)
• Naratriptan (Amerge)
• Rizatriptan (Maxalt)
• Sumatriptan (Imitrex, Onzetra, Xsail, Sumavel, DosePro, Zembrace)
• Zolmitriptan (Zomig)

Please select one… 1 2 or more

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Did you experience intolerable side effects when taking Triptan medication(s) for the relief of your migraine symptoms? * Please select one… Yes – I experienced intolerable side effects No

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Was there any improvement of your migraine symptoms with the Triptan medications you have tried? * Please select one... No improvement to migraine symptoms Improvement to migraine symptoms Unsure

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In the past, have you required the use of oral preventive medications for migraine? *
(Examples of preventive migraine therapies include: Dyzantil, Epilim, Episenta, Epival, FusePaq Fanatrex, Gabarone, Gralise, Neurontin, Eprontia, Qudexy XR, Topamax, Topiragen, Trokendi XR, Tenormin, Cardicor, Congescor, Lopressor, Toprol XL, Corgard, Inderal LA, Timoptic, Elavil, Khedezla, Pristiq, Vensir, Vencarm, Venlalix, Efexor, Venlablue, Sibelium, Verelan PM, Amias, Zestril, Deseril, Sansert, Oxetrone, Sandomigran) Please select one... Yes No

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How many previous oral preventative migraine medications have you tried? * Please select one... 5-6+ 2-4 0-1

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Did the above oral migraine medications work to prevent your migraine attacks? * Please select one… No – they do not prevent my migraine attacks Sometimes Yes – they prevent my migraine attacks all the time

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Have you been told by your doctor that you should not use a specific oral migraine preventive medication for medical reasons? * Please select one… Yes - I have been told by my doctor that I should not use a specific oral migraine preventive medication for medical reasons No - I have not been told by my doctor that I should not use a specific oral migraine preventive medication for medical reasons

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Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: chronic pancreatitis, ulcerative colitis, gallstones, cancer, schizophrenia, bipolar disorder, borderline personality disorder, major depression, anxiety, fibromyalgia, chronic pelvic pain, complex regional pain syndrome (CRPS), dementia, cardiovascular disease, stroke, hepatitis).
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

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

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Please, select your height from the dropdown below. * Please select one... 4'0" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11"

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How much do you weigh in Lbs (pounds)? *

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If female, are you currently pregnant or breastfeeding? Please select one... Yes No N/A - Male

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

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