Headache Australia - Questionnaire

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USERNAME:

PASSWORD:

Headache Australia relies on the generosity of the community. To support our work, please click below:

A database is being started for those suffering migraines and chronic headache. It is our hope that as many as possible will be part of this initiative so that we can keep you directly informed about new treatments. The greater the number of people in the database, the greater is our chance of gaining more for research to end the suffering and reliance on medications.

Completing this form means that you are happy for us to contact you in future. We never pass on individual information and you may withdraw if you wish anytime, as per the Privacy Laws.

To cancel submission and return to the homepage at any time click here

Questionaire

1. From which do you suffer?

	Migraine
	Chronic Headache

2. How many years have you been affected?

3. How often do you suffer?

Times per week? OR

Times per month?

4. Have you been treated by a

	GP
	Neurologist

Other (please specify)

5. What medications do you use now?

6. What other kinds of treatment have you undertaken?

7. Gender:

	Male
	Female

8. Age group:

	<20
	21-30
	31-40
	41-50
	51-60
	>60

9. Would you like to be informed about opportunities to participate in research projects?
We will advise when research is scheduled and explain what is involved so you can make contact with the researcher if you choose. We will never make any details about individuals available.

	Yes
	No

Email address:
Our preferred method of contact is via email.

First Name:

Last Name:

Address Line 1:

Address Line 2:

Suburb:

State:

Post Code:

Telephone:
For example (02) 1234 5678

Mobile:
For example 1234 456 789

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