Migraine Study Intake Form
Please complete this form to participate in the migraine research study. Your responses will help us understand your migraine experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Non-binary
Prefer not to say
Other
At what age did your migraines begin?
How often do you experience migraines?
*
Please Select
Less than once a month
1-3 times per month
Once a week
Several times a week
Daily
How long do your migraines usually last?
*
Please Select
Less than 4 hours
4-12 hours
12-24 hours
More than 24 hours
Which of the following symptoms do you typically experience with your migraines? (Select all that apply)
Nausea or vomiting
Sensitivity to light
Sensitivity to sound
Visual disturbances (aura)
Throbbing or pulsating pain
Dizziness
Other
Please rate the typical severity of your migraines:
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
What triggers your migraines? (Select all that apply)
Stress
Certain foods or drinks
Hormonal changes
Lack of sleep
Weather changes
Other
What treatments or medications have you tried for your migraines? Please specify effectiveness if possible.
Do you have any other medical conditions?
Submit Intake Form
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