Fields marked with an * are required.

Would you like to be contacted about taking part in a Clinical Trial that you – or the Potential Participant (if filling this out for them) - may qualify for? *

Yes

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If you are under the age of 13 (or 16 if you are in California), you may not directly enter any information and your legal parent or guardian must enter this information on your behalf. By filling out this form, you are confirming that you meet these requirements. 

Who are you interested in this study for? * Please select one... My Child The Child I Care For Other

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First Name of Potential Participant *

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Last Name of Potential Participant *

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Date of Birth MM/DD/YYYY of Potential Participant *

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Zip Code or Postal Code of Potential Participant *

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Is the Potential Participant Male or Female? Please select one... Female Male Prefer not to say

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Does the Potential Participant suffer from migraine headaches? * Please select one… Yes – the Potential Participant suffers from migraine headaches No

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Has the Potential Participant been experiencing migraine headaches for at least 6 months? * Please select one… Yes No

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On average, out of a 30-day month, how many days does the Potential Participant have a migraine? *

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If left untreated, do the Potential Participant’s migraine headaches typically last at least 3 hours? * Please select one… Yes No I don't know

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Has the Potential Participant ever taken any medication to treat a migraine? *
These may include Acetaminophen (Tylenol), Ibuprofen (Advil, Advil Migraine, Motrin), Naproxen (Aleve), Aspirin or medications prescribed by your doctor for migraine. Please select one… Yes – the Potential Participant has tried at least one treatment for migraine No I don't know

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Has the Potential Participant been diagnosed (by a doctor) with any other medical conditions? *
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

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

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Is the Potential Participant between 44 and 297 lbs? * Please select one… Yes No I am unsure

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If the Potential Participant is female, is she currently pregnant or breastfeeding? * Please select one… Yes No N/A- Male

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First Name of caregiver/parent to contact *

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Last Name of caregiver/parent to contact *

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Phone Number of caregiver/parent to contact *

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Email of caregiver/parent to contact *

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

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The information you are providing here will only be used to match you or a loved one to a clinical research study in the potential participant’s area and contact you to see if you or a loved one would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.

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