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<form enctype="multipart/form-data" role="form" method="POST" id="form" novalidate="novalidate"><input type="hidden" name="csrfmiddlewaretoken" value="ZYZsfc3iibJdim2qeux131hIIhr516mdIp2yZJHYwxA9eIO4Y1Sx3r4DMPy4alxN"> <label
    class="form-text required-warning"> Fields marked with an * are required. </label>
  <p class="error"></p>
  <div class="form-group"><label for="id_name" class="control-label">First Name *</label> <span><input type="text" name="name" placeholder="First Name" autocomplete="given-name" required="required" id="id_name" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_last_name" class="control-label">Last Name *</label> <span><input type="text" name="last_name" placeholder="Last Name" autocomplete="family-name" required="required" id="id_last_name" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_phone_number" class="control-label">Phone number *</label> <span><input type="text" name="phone_number" placeholder="Phone number" autocomplete="tel-national" required="required" id="id_phone_number"
        class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_email" class="control-label">Email&nbsp;</label> <span><input type="text" name="email" placeholder="Email" autocomplete="email" id="id_email" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_date_of_birth" class="control-label">Date of Birth MM/DD/YYYY *</label> <span>
      <div data-v-6c52109e="" class="triple-date-picker form-control" placeholder="Date of Birth MM//DD/YYYY" autocomplete="bday" data-type="date" data-provide="datepicker" required="required" id="id_date_of_birth">
        <div data-v-6c52109e="" class="date-input-container month-container"><input data-v-6c52109e="" id="month" type="number" autocomplete="bday-month" placeholder="MM" class="month"></div> <span data-v-6c52109e="">/</span>
        <div data-v-6c52109e="" class="date-input-container day-container"><input data-v-6c52109e="" id="day" type="number" autocomplete="bday-day" placeholder="DD" class="day"></div> <span data-v-6c52109e="">/</span>
        <div data-v-6c52109e="" class="date-input-container year-container"><input data-v-6c52109e="" id="year" type="number" autocomplete="bday-year" placeholder="YYYY" class="year"></div> <!----> <input data-v-6c52109e="" type="hidden"
          name="date_of_birth">
      </div>
      <div class="help-block"><!----> <!---->
        <div class="help is-danger errorlist error bg-danger"></div>
      </div>
    </span></div>
  <div class="form-group"><label for="id_zip_code" class="control-label">Zip Code or Postal Code *</label> <span><input type="text" name="zip_code" placeholder="Zip Code or Postal Code" autocomplete="postal-code" required="required" id="id_zip_code"
        class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_sex_mf" class="control-label">Are you Male or Female?</label> <span><select name="sex_mf" placeholder="Please select one..." autocomplete="off" id="id_sex_mf" class="form-control">
        <option value="" selected="selected">Please select one...</option>
        <option value="Male">Male</option>
        <option value=" Female"> Female</option>
        <option value=" Prefer not to say"> Prefer not to say</option>
      </select>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_migraines_least_1_year" class="control-label">Have you been experiencing migraines for at least 1 year? *</label> <span><select name="migraines_least_1_year" placeholder="Please select one..."
        autocomplete="off" required="required" id="id_migraines_least_1_year" class="form-control">
        <option value="" selected="selected">Please select one...</option>
        <option value="Yes">Yes</option>
        <option value="No">No</option>
      </select>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_migraine_days_per_month" class="control-label">On average, out of a 30-day month, how many days do you have a migraine? *</label> <span><input type="number" name="migraine_days_per_month"
        placeholder="Please enter a number..." autocomplete="off" min="0.0" max="15.0" required="required" id="id_migraine_days_per_month" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_age_migraine_symptoms_began" class="control-label">At what age did your migraine symptoms <u>begin</u>? *</label> <span><input type="number" name="age_migraine_symptoms_began"
        placeholder="Please enter a number" autocomplete="off" min="0.0" max="99.0" required="required" id="id_age_migraine_symptoms_began" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="" class="control-label">Which of the following medications have you tried, or are currently trying, for prevention of your migraines? * <br> Please select all that apply, including those you have tried in the
      past.</label> <span>
      <div id="id_migraine_medication" class="multi_checkbox_item" style="max-height: 20em;">
        <div><label for="id_migraine_medication_0"><input type="checkbox" name="migraine_medication" value="Divalproex sodium (valproic acid or sodium valproate) (Depakote)" placeholder="" autocomplete="off" max_height="20em"
              id="id_migraine_medication_0" class="multi_checkbox_item"> Divalproex sodium (valproic acid or sodium valproate) (Depakote)</label></div>
        <div><label for="id_migraine_medication_1"><input type="checkbox" name="migraine_medication" value="Topiramate (Topamax)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_1" class="multi_checkbox_item">
            Topiramate (Topamax)</label></div>
        <div><label for="id_migraine_medication_2"><input type="checkbox" name="migraine_medication" value="Amitriptyline (Elavil)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_2" class="multi_checkbox_item">
            Amitriptyline (Elavil)</label></div>
        <div><label for="id_migraine_medication_3"><input type="checkbox" name="migraine_medication" value="Nortriptyline (Pamelor)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_3" class="multi_checkbox_item">
            Nortriptyline (Pamelor)</label></div>
        <div><label for="id_migraine_medication_4"><input type="checkbox" name="migraine_medication" value="Metoprolol (Toprol-XL or Lopressor)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_4"
              class="multi_checkbox_item"> Metoprolol (Toprol-XL or Lopressor)</label></div>
        <div><label for="id_migraine_medication_5"><input type="checkbox" name="migraine_medication" value="Bisoprolol (Ziac)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_5" class="multi_checkbox_item"> Bisoprolol
            (Ziac)</label></div>
        <div><label for="id_migraine_medication_6"><input type="checkbox" name="migraine_medication" value="Atenolol (Tenormin)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_6" class="multi_checkbox_item"> Atenolol
            (Tenormin)</label></div>
        <div><label for="id_migraine_medication_7"><input type="checkbox" name="migraine_medication" value="Nadolol (Corgard)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_7" class="multi_checkbox_item"> Nadolol
            (Corgard)</label></div>
        <div><label for="id_migraine_medication_8"><input type="checkbox" name="migraine_medication" value="Propranolol (Inderal)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_8" class="multi_checkbox_item">
            Propranolol (Inderal)</label></div>
        <div><label for="id_migraine_medication_9"><input type="checkbox" name="migraine_medication" value="Timolol (Timol)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_9" class="multi_checkbox_item"> Timolol
            (Timol)</label></div>
        <div><label for="id_migraine_medication_10"><input type="checkbox" name="migraine_medication" value="Flunarizine (Sibelium)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_10" class="multi_checkbox_item">
            Flunarizine (Sibelium)</label></div>
        <div><label for="id_migraine_medication_11"><input type="checkbox" name="migraine_medication" value="Candesartan (Atacand)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_11" class="multi_checkbox_item">
            Candesartan (Atacand)</label></div>
        <div><label for="id_migraine_medication_12"><input type="checkbox" name="migraine_medication" value="Lisinopril (Prinivil or Zestril)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_12"
              class="multi_checkbox_item"> Lisinopril (Prinivil or Zestril)</label></div>
        <div><label for="id_migraine_medication_13"><input type="checkbox" name="migraine_medication" value="Desvenlafaxine (Pristiq)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_13" class="multi_checkbox_item">
            Desvenlafaxine (Pristiq)</label></div>
        <div><label for="id_migraine_medication_14"><input type="checkbox" name="migraine_medication" value="Venlafaxine (Effexor)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_14" class="multi_checkbox_item">
            Venlafaxine (Effexor)</label></div>
        <div><label for="id_migraine_medication_15"><input type="checkbox" name="migraine_medication" value="Erenumab (Aimovig)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_15" class="multi_checkbox_item"> Erenumab
            (Aimovig)</label></div>
        <div><label for="id_migraine_medication_16"><input type="checkbox" name="migraine_medication" value="Fremanezumab (Ajovy)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_16" class="multi_checkbox_item">
            Fremanezumab (Ajovy)</label></div>
        <div><label for="id_migraine_medication_17"><input type="checkbox" name="migraine_medication" value="Galcanezumab (Emgality)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_17" class="multi_checkbox_item">
            Galcanezumab (Emgality)</label></div>
        <div><label for="id_migraine_medication_18"><input type="checkbox" name="migraine_medication" value="Eptinezumab (Vyepti)" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_18" class="multi_checkbox_item">
            Eptinezumab (Vyepti)</label></div>
        <div><label for="id_migraine_medication_19"><input type="checkbox" name="migraine_medication" value="None of the above" placeholder="" autocomplete="off" max_height="20em" id="id_migraine_medication_19" class="multi_checkbox_item"> None of
            the above</label></div>
      </div>
      <div class="help-block"><!---->
        <div></div> <!---->
      </div>
    </span></div>
  <div class="form-group"><label for="id_patient_has_tried_following_preventative_migraine_medications" class="control-label">What prescription or over the counter medications are you currently taking for your migraines? *<br>Please list them below,
      or type 'none'.</label> <span><input type="text" name="patient_has_tried_following_preventative_migraine_medications" placeholder="Please type here..." autocomplete="off" required="required"
        id="id_patient_has_tried_following_preventative_migraine_medications" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_other_medical_conditions" class="control-label">Have you been diagnosed (<u>by a doctor</u>) with any other medical conditions? *<br>Please list here or write 'none'. <br>Please only include conditions which
      have been diagnosed by a doctor.</label> <span><input type="text" name="other_medical_conditions" placeholder="Please type here..." autocomplete="off" required="required" id="id_other_medical_conditions" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_other_medication" class="control-label">If you are taking any medications for other health conditions, please list them below. *</label> <span><input type="text" name="other_medication"
        placeholder="Please type here..." autocomplete="off" required="required" id="id_other_medication" class="form-control">
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_patient_has_had_botulinum_toxin_botox_injection_their_face_within_last_6_months" class="control-label">Have you had botulinum toxin A injections in your head, face, or neck (for cosmetic purposes and/or help
      treat your migraines) in the past? *</label> <span><select name="patient_has_had_botulinum_toxin_botox_injection_their_face_within_last_6_months" placeholder="Please select one…" autocomplete="off" required="required"
        id="id_patient_has_had_botulinum_toxin_botox_injection_their_face_within_last_6_months" class="form-control">
        <option value="" selected="selected">Please select one…</option>
        <option value="Yes">Yes</option>
        <option value="No">No</option>
      </select>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_would_you_be_willing_refrain_use_cannabis_during_study" class="control-label">Are you willing to refrain from marijuana use (including CBD oil and other cannabinoids such as THC and CBN) for the duration of
      the study? *<br> This is required for participation.</label> <span><select name="would_you_be_willing_refrain_use_cannabis_during_study" placeholder="Please select one…" autocomplete="off" required="required"
        id="id_would_you_be_willing_refrain_use_cannabis_during_study" class="form-control">
        <option value="" selected="selected">Please select one…</option>
        <option value="Yes - I am willing to refrain">Yes - I am willing to refrain</option>
        <option value="No">No</option>
        <option value="I am unsure">I am unsure</option>
      </select>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_pregnant" class="control-label">If female, are you currently pregnant, or breastfeeding?</label> <span><select name="pregnant" placeholder="Please select one..." autocomplete="off" id="id_pregnant"
        class="form-control">
        <option value="" selected="selected">Please select one...</option>
        <option value="Yes">Yes</option>
        <option value="No">No</option>
        <option value="N/A - Male">N/A - Male</option>
      </select>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_how_candidate_woud_lke_be_reached" class="control-label">What is the best day/time to reach you via telephone (we know you are busy)? *</label> <span><textarea name="how_candidate_woud_lke_be_reached"
        cols="40" rows="5" placeholder="Please type here..." autocomplete="off" required="required" id="id_how_candidate_woud_lke_be_reached" class="form-control"></textarea>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div>
  <div class="form-group"><label for="id_consent" class="control-label">Would you like to be contacted about taking part in a Clinical Trial? *</label> <span>
      <div><label for="id_consent"><input type="checkbox" name="consent" placeholder="Please select one..." autocomplete="off" help_text="Yes" required="required" id="id_consent"> Yes </label></div>
      <div class="help-block"><!----> <!----> <!----></div>
    </span></div> <input type="hidden" name="cid" id="cid" value=""> <input type="hidden" name="agid" id="agid" value=""> <input type="hidden" name="fiid" id="fiid" value=""> <input type="hidden" name="tid" id="tid" value=""> <input type="hidden"
    name="loc" id="loc" value=""> <input type="hidden" name="mt" id="mt" value=""> <input type="hidden" name="an" id="an" value=""> <input type="hidden" name="dt" id="dt" value=""> <input type="hidden" name="dm" id="dm" value=""> <input type="hidden"
    name="aid" id="aid" value=""> <input type="hidden" name="kw" id="kw" value=""> <input type="hidden" name="pl" id="pl" value=""> <input type="hidden" name="t" id="t" value=""> <input type="hidden" name="apos" id="apos" value="">
  <p class="error"></p>
  <div class="form-group submit-button-wrapper"><button type="submit" class="btn btn-primary btn-lg">Submit</button></div>
</form>

Text Content

DO YOU SUFFER FROM MIGRAINES?


WOULD YOU LIKE TO TAKE PART IN A CLINICAL STUDY INVESTIGATING A DRUG FOR
MIGRAINES?

Volunteers who take part in the study may be compensated for time and travel.

Sign up and we will notify you of clinical trials in your area that need
participants with migraines.

No health insurance is required to participate. All study-related visits, care,
and the investigational drug will be provided at no cost. The study will involve
visits to a study site in your area.

Sign up to take part in a clinical trial.


WHAT HAPPENS IF I SIGN UP?

You may be eligible to participate in a migraine clinical research study, also
known as a clinical trial in your area. Someone from the study team or research
site conducting the trial will contact you to explain more about this clinical
research study before you make your decision about participating.


SIGN UP

Fields marked with an * are required.



First Name *

Last Name *

Phone number *

Email 

Date of Birth MM/DD/YYYY *

/

/


Zip Code or Postal Code *

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

Have you been experiencing migraines for at least 1 year? * Please select one...
Yes No

On average, out of a 30-day month, how many days do you have a migraine? *

At what age did your migraine symptoms begin? *

Which of the following medications have you tried, or are currently trying, for
prevention of your migraines? *
Please select all that apply, including those you have tried in the past.
Divalproex sodium (valproic acid or sodium valproate) (Depakote)
Topiramate (Topamax)
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Metoprolol (Toprol-XL or Lopressor)
Bisoprolol (Ziac)
Atenolol (Tenormin)
Nadolol (Corgard)
Propranolol (Inderal)
Timolol (Timol)
Flunarizine (Sibelium)
Candesartan (Atacand)
Lisinopril (Prinivil or Zestril)
Desvenlafaxine (Pristiq)
Venlafaxine (Effexor)
Erenumab (Aimovig)
Fremanezumab (Ajovy)
Galcanezumab (Emgality)
Eptinezumab (Vyepti)
None of the above

What prescription or over the counter medications are you currently taking for
your migraines? *
Please list them below, or type 'none'.

Have you 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.

If you are taking any medications for other health conditions, please list them
below. *

Have you had botulinum toxin A injections in your head, face, or neck (for
cosmetic purposes and/or help treat your migraines) in the past? * Please select
one… Yes No

Are you willing to refrain from marijuana use (including CBD oil and other
cannabinoids such as THC and CBN) for the duration of the study? *
This is required for participation. Please select one… Yes - I am willing to
refrain No I am unsure

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

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

Would you like to be contacted about taking part in a Clinical Trial? *
Yes




Submit

The information you are providing here will only be used to match you 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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