Migraine Research Study

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

SiteId

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Eligibility Status

Have you been diagnosed with Migraines, either Acute Migraine or Moderate to Severe Migraine, for at least 1 year?

Were you diagnosed with Migraines after the age of 50?

Do you have history of any of the following- (Please check all that apply

Do the duration of your Migraines - (Please check all that apply)

Do you take any medications for Migraines?

Have you of taken any of the following medications- (Please check all that apply)

If Yes to any of the above, has that medication’s dose changed, or plan to change?

Do you of take any of the following medications- (Please check all that apply)

If Yes to any of the above medications, are you willing to refrain from them for the duration of this study?

Have you been diagnosed with any of the following conditions- (Please check all that apply)

If you would like to provide more detail, i.e. description of the condition(s), current treatment, and approximate date of diagnosis.

Do we have consent to reach out to you for current and future trials?